骨质疏松性骨折应对策略——骨折联络服务研究进展及应用探讨

骨质疏松性骨折是病理性骨折的一种,初发骨折后再发骨折概率高,严重危害中老年人健康。国际骨质疏松协会提出的骨折联络服务是有效预防再发骨折的重要策略,其核心环节包括:识别骨质疏松性骨折、评估骨质疏松治疗的必要性及再发骨折风险、根据指南进行骨质疏松初始治疗、提高患者治疗的依从性并减少再发骨折。该策略经欧美各国实践检验显示了良好的经济效益和社会效益,目前在我国的应用尚属起步阶段,本文基于国内医疗资源配置的特殊性,分析骨质疏松性骨折诊疗现况,结合国际骨折联络服务发展进程及其在亚太地区的应用情况,分析我国骨质疏松性骨折后多学科协作诊疗的有利条件及阻碍因素,探讨我国该模式应用的必要性和可行性,拟为骨折联络服务在我国的应用提供理论基础。     

FRAX工具在慢性肾脏病骨质疏松性骨折风险评估中的研究进展

骨质疏松性骨折是骨质疏松症严重的并发症,临床上有效的预防和减少骨质疏松性骨折可以缓解社会的经济压力以及减少医疗资源的浪费.FRAX是2008年世界卫生组织(WHO)推荐的骨折风险评估工具,其简便且相对准确的优点得到了国内外众多国家指南的推荐.现阶段FRAX广泛应用于原发性或者多种继发性骨质疏松性骨折的风险概率评估,并且...     

Orthogeriatric co-management – managing frailty as well as fragility

A high proportion of patients with fragility fracture, mainly hip fracture, have a variable degree of comorbidity and show some degree of dependence in basic or more complex activities of daily living. Evaluating these patents following the geriatric concept of frailty, about one third of hip fracture patients may be categorised as frail with high risk of poor outcomes and prolonged length of stay, one third as not frail, and about one third with an intermediate condition. Due to the high vulnerability, combined with the hip fracture event and surgical repair procedures, a multidisciplinary approach that includes geriatric competencies becomes essential to improve short and long-term outcomes after hip fracture. A key element of an effective process of care is a true co-managed approach that applies quality standards and provides a fast-track pathway of care, minimises the time the patient spends in bed, and reduces postoperative complications by means of standardised procedures.The occurrence of a fragility fracture is the strongest risk factor for a subsequent fracture. Moreover, frail subjects have a further risk of fracture due to high risk of falls − related to loss of muscle mass, multiple illnesses, impaired balance and weakness. Thus, effective secondary prevention strategies are essential to reduce morbidity and mortality after hip fracture, and they are currently a standard task of orthogeriatric care. Fracture liaison services (FLS) are probably the most efficient way of addressing secondary prevention including the assessment of both bone health and falls risk. Therefore, the optimal management of frail patients with fragility fracture includes both orthogeriatric care and FLS, which are complementary to each other.Orthogeriatric collaboration is also powerful in influencing healthcare policy. British experience as well as that in Ireland, Australia and New Zealand, have shown that when two widely disparate specialisms say the same thing, they may achieve a fundamental shift in attitudes and behaviour of both managers and clinicians. Furthermore, a continuous real-time audit, at national level, is a powerful driver for change and better standards of care.     

Failure in the application of fragility fracture prevention guidelines

Introduction

The cost of fragility fractures to the UK economy is predicted to reach £2.2 billion by 2025. We studied our hip fracture population to establish whether national guidelines on fragility fracture prevention were being followed, and whether high risk patients were identified and treated by local care services.

Methods

Data on a consecutive series of trauma hip fracture admissions were collected prospectively over 14 months. National Institute for Health and Care Excellence (NICE) and National Osteoporosis Guideline Group (NOGG) recommendations and FRAX^® risk calculations were applied to patients prior to their admission with a new hip fracture.

Results

Overall, 94 patients were assessed against national guidelines. The mean population age was 77 years. Almost a quarter (22%) of patients had suffered a previous fragility fracture. The mean FRAX^® ten-year probability of hip fracture was 7%. According to guidelines, 45% of the study population required treatment, 35% fulfilled criteria for investigation and reassessment, and 20% needed no further management. In practice, 27% received treatment, 4% had undergone dual energy x-ray absorptiometry and were untreated, and 69% had not been investigated and were untreated. In patients meeting intervention thresholds, only 33% of those who required treatment were receiving treatment in practice.

Conclusions

In conjunction with NICE and NOGG recommendations, FRAX^® was able to identify 80% of our fracture population as intermediate or high risk on the day of fracture. Correct management was evident in a third of cases with a pattern of inferior guideline compliance seen in a London population. There remains a lack of clarity over the duty of care in fragility fracture prevention.     

Secondary prevention of osteoporosis: Calcium, Vitamin D and bisphosphonate prescribing following distal radial fracture

Over 200,000 osteoporotic fractures occur in the UK annually. Patients with fragility fractures are at highest risk of further fracture, though preventative treatment has been shown to reduce subsequent fracture incidence. We reviewed the pre- and post-fracture medication (via the PCTs and in-patient discharge letters) of all patients over 55 years who suffered a distal radial fracture between April 2003 and November 2004. Complete data was available for 175 patients (170 female): 95 were in-patients, 80 out-patients. Following distal radial fracture, calcium and Vitamin D was prescribed for 39 patients (22%), bisphosphonates to 16 patients (9%) and only 15 patients (8.5%) were referred for DEXA scanning. Higher rates of prescribing were seen in hospital, with over half of all in-patients started on fracture prevention treatment; however, less than a half of these patients continued to receive this medication in primary care. We believe, the results demonstrate a lack of health promotion opportunities to prevent future fracture, which is a common finding across healthcare systems nationally. Although there is clear focus and impetus for developing falls prevention services nationwide, this enthusiasm has not been translated across to bone health, despite the potential savings in terms of morbidity, mortality and healthcare costs. Important deficiencies in local services have been identified, particularly with respect to communication between secondary and primary care. This study has added weight to secure funding for a fracture liaison nurse in our institution; we suggest others follow suit and employ similarly dedicated personnel to ensure assessment and treatment for the prevention of further fractures.     

Fracture Liaison Services in the United Kingdom

Fracture Liaison Services (FLS) have been demonstrated to be a clinically and cost-effective means of providing secondary preventive care for patients presenting with new fragility fractures. This review summarizes the emergence and widespread adoption of the FLS model in the United Kingdom. Large scale national audits have clearly illustrated the need for FLS by revealing the care gap experienced by the majority of patients who suffer fragility fractures. Since 2003, FLS has featured increasingly more prominently in relevant national professional guidance. During the last 5 years that professional consensus has led to FLS being embedded in government policy on fracture prevention. Quality incentives have been created to encourage hospitals and primary care providers to pro-actively deliver best practice. The strategic approaches taken and lessons learned in the UK may have relevance to quality improvement efforts in other jurisdictions.     

Incidence and outcome of osteoporotic fractures in 2004 in Sado City,Niigata Prefecture,Japan

Osteoporotic fracture in elderly populations is increasing worldwide, but there are few data on the incidence and outcome of osteoporotic fractures, including upper extremity and vertebral fracture, during a certain period in a defined geographic area. The purpose of this study was to determine the incidence of osteoporotic fractures in a particular area: Sado City, Niigata Prefecture, Japan. From January to December 2004, osteoporotic fractures of the vertebra, hip, distal radius, and proximal humerus in Sado City were recorded. The incidence, age, gender, type of fracture (for hip fracture), right or left side (for distal radius, proximal humerus, and hip fracture), place of injury, cause of injury, outcome, hospitalization period, and patient status regarding taking of drugs for osteoporosis treatment were checked for each fracture. The incidence was calculated based on the whole population of Sado City. The incidence per 100,000 population was 232.8, 121.4, 108.6, and 37.1 for fractures of the vertebra, hip, distal radius, and proximal humerus, respectively. The total incidence of these four kinds of fracture was 499.9 per 100,000 persons per year. The average age at the time of injury was 81.4, 77.7, 75.7, and 60.2 years old for fractures of the hip, vertebra, proximal humerus, and distal radius, respectively. As the average age increased, the percentage of fractures that occurred indoors also increased; that is, a higher percentage of hip fractures occurred indoors, followed by fractures of the vertebra, proximal humerus, and distal radius. Most patients were not taking anti-osteoporosis drugs before fractures of the hip or vertebra. We determined the incidence of major osteoporotic fractures in 1 year in a defined geographic area. Our data showed that 81% of hip fracture patients also had a vertebral fracture and that the average age at the time of injury was higher for hip fractures than for vertebral fractures. Therefore, these results suggest that vertebral fracture leads to hip fracture, indicating that early fracture prevention and continuous prevention strategies through positive treatment are of importance in osteoporotic elderly people.     

A global call to action to improve the care of people with fragility fractures

The ageing of society is driving an enormous increase in fragility fracture incidence and imposing a massive burden on patients, their families, health systems and societies globally. Disrupting the status quo has therefore become an obligation and a necessity.Initiated by the Fragility Fracture Network (FFN) at a “Presidents' Roundtable” during the 5^th FFN Global Congress in 2016 several leading organisations agreed that a global multidisciplinary and multiprofessional collaboration, resulting in a Global Call to Action (CtA), would be the right step forward to improve the care of people presenting with fragility fractures. So far global and regional organisations in geriatrics/internal medicine, orthopaedics, osteoporosis/metabolic bone disease, rehabilitation and rheumatology were contacted as well as national organisations in five highly populated countries (Brazil, China, India, Japan and the United States), resulting in 81societies endorsing the CtA.We call for implementation of a systematic approach to fragility fracture care with the goal of restoring function and preventing subsequent fractures without further delay.There is an urgent need to improve:

• •Acute multidisciplinary care for the person who suffers a hip, clinical vertebral and other major fragility fractures
• •Rapid secondary prevention after first occurrence of all fragility fractures, including those in younger people as well as those in older persons, to prevent future fractures
• •Ongoing post-acute care of people whose ability to function is impaired by hip and major fragility fractures

To address this fragility fracture crisis, the undersigned organisations pledge to intensify their efforts to improve the current management of all fragility fractures, prevent subsequent fractures, and strive to restore functional abilities and quality of life.     

Health care costs of women with symptomatic vertebral fractures

BACKGROUND: An important aspect of the economics of fracture prevention is averted fracture costs. However, while vertebral fractures represent a significant burden to society, quantifying their cost is difficult for several reasons. In this paper, we examine the health care costs of symptomatic vertebral fractures occurring in women aged 50 years and above in the UK. METHODS: We used a variety of data sources. The prevalence of pharmaceutical treatment for fracture prevention and number of general practitioner consultations, referrals, and hospital admissions associated with a diagnosis of vertebral fracture were identified from a case control study. For the unit cost of a general practitioner consultation, referral, and cost per inpatient day, we used 2002 data produced by the Personal Social Services Research Unit. Hospital Episode Statistics (HES) for 2001-2002 were used to estimate the median length of stay in hospital for women aged 50 years and above, and the Monthly Index of Medical Specialities (MIMS) was used to identify the costs of pharmaceutical treatments. Costs were discounted at 6%. RESULTS: From these data, we estimated that for the year prior and post diagnosis the average additional health care costs for those diagnosed with vertebral fracture were pounds 165, pounds 134, and pounds 2314 for general practitioner consultations, referrals, and hospital admissions, respectively (i.e., pounds 2613). The cost of pharmaceutical treatments prescribed for fracture prevention in the year following diagnosis was pound 97. DISCUSSION: Vertebral fractures are associated with significantly increased health care costs. These costs need to be set against the costs of fracture prevention.     

Hip fracture audit: Creating a ‘critical mass of expertise and enthusiasm for hip fracture care’?

The care of frail older people admitted with hip fracture has improved greatly over the last half-century, largely as a result of combined medical care and surgical care and the rise – over the last four decades – of large-scale hip fracture audit.A series of European initiatives evolved. The first national hip fracture audit was the Swedish Rikshöft in the late 1980s, and the largest so far is the UK National Hip Fracture Database (NHFD), launched in 2007. An external evaluation of the NHFD demonstrated statistically significant increases in survival at up to 1 year associated with improved early care: with rising geriatrician involvement and falling delays to surgery, and from which lessons have been learned.Comparable national audits have emerged since in northern Europe and in Australia and New Zealand, and most recently in Spain and Japan. Like the NHFD, these use the synergy of agreed clinical standards and regular – ideally continuous – audit feedback that can prompt and monitor clinical and service developments, often demonstrating both rising quality and improved cost effectiveness.In addition, important benchmarking studies of hip fracture care have been reported from India and China, both of which face huge challenges in providing care of fragility fractures in populations characterised by first-generation mass ageing. The ‘halo effect’ of the impact of growing expertise in hip fracture care on the care of other fragility fractures is noteworthy and now relevant globally.Although many national audits have now published encouraging reports of progress, the details of context and process determinants of the initiation and development of effective hip fracture audit have received relatively little attention.To address this, an extended discussion section – based on the author’s experience of participation in several substantial audits, variously supporting and observing many others, and from his numerous discussions with audit colleagues over the years – may be of value in offering practical advice on some obvious and less obvious practical issues that arise in the setting up of large-scale hip fracture audits in a variety of healthcare contexts.     

The contribution of hip fracture to risk of subsequent fractures: data from two longitudinal studies

Background: The contribution of hip fracture to the risk of subsequent fractures is unclear. Methods: Data from the Baltimore Hip Studies and the Established Populations for Epidemiologic Studies of the Elderly (EPESE) were used. Baltimore subjects enrolled at the time of hip fracture (n=549) and EPESE subjects without previous fractures at baseline (n=10,680) were followed for 2–10 years. Self-reported nonhip skeletal fracture was the outcome, and hip fracture was a time-varying covariate in a survival analysis stratified by study site. The model was adjusted for race, sex, age, BMI, stroke, cancer, difficulty walking across a room, dependence in grooming, dependence in transferring, and cognitive impairment. Results: The rate of all subsequent self-reported fractures after hip fracture was 10.4 fractures/100 person-years. The unadjusted hazard of nonhip skeletal fracture was 2.52 (95% confidence interval 2.05 to 3.12) for subjects with hip fracture compared with subjects without; when adjusted for other known fracture risk factors the hazard ratio was 1.62 (1.30 to 2.02). Men and women had a similar relative risk increase. The increased risk of secondary fracture after hip fracture persisted over time. Conclusions: A hip fracture is associated with a 2.5-fold increased risk of subsequent fracture, which is not entirely explained by prefracture risk factors. Careful attention to secondary prevention is warranted in these patients.     

A study of bone mineral density in women with forearm fracture in Northern Ireland

A group of Northern Ireland women aged 40–75 years of age with low-trauma forearm fracture were studied to determine the incidence of such fractures and the prevalence of osteoporosis in this fracture population. A total of 1,147 subjects were identified in 1997 and 1998 throughout Northern Ireland following low-trauma forearm fractures, as well as 699 residents in the Eastern Health and Social Services Board (EHSSB), enabling calculation of the annual incidence rate of new low-trauma forearm fractures at 2.69/1,000 population aged 40–75. A total of 375 participants consented to have bone mineral density (BMD) measurements undertaken at the femoral neck, spine, and forearm using a Lunar Expert bone densitometer. Osteoporosis at the femur was present in 14% of women, at the spine in 29%, and at the forearm in 32%. A total of 45% were osteoporotic at one or more measured sites, but only 18% were on treatment for osteoporosis. Additional significant risk factors identified included an early menopause in 24.5% and current or previous corticosteroid use in 13%. Only 1.6% received information on treatment of osteoporosis at the time of fracture. Increased awareness is needed in both primary and secondary care including fracture services to improve treatment of women with low-trauma fracture.     

Bone quality: Implications in geriatricorthopaedic patients

Bone quality is an important component of orthopaedic care in geriatric patients because it relates to fracture risk andprevention, fracture treatment and fixation techniques, and implant/bone interface stability. Quality includes static parameters such as bone strength (density) and dynamic parameters (physiologic functions) including bone formation, resorption, and repair. All of these change with normal bone aging. Techniques are available to assess the parameters of quality including bone mineral density measurement, biochemical markers of bone turnover, and histomorphometry. Treatment regimes are available to alter the rates of bone resorption and formation. These include estrogen, bisphosphonates, calcitonin, selective estrogen receptor modulators, and parathyroid hormone. Using these tools, progress is being made in fracture risk assessment and prevention strategies, enhancement of fracture fixation in aging bone, and control of periprosthetic bone resorption after total joint arthroplasty. More information and additional studies are needed as these modalities continue to evolve but significant potential now exists for improving orthopaedic care in the geriatric patient if we are willing to put these tools to work.     

The Official Positions of the International Society for Clinical Densitometry: Vertebral Fracture Assessment

Vertebral fracture assessment (VFA) is a low-cost method of accurately identifying individuals who have clinically unrecognized or undocumented vertebral fractures at the time of bone density test. Because prevalent vertebral fractures predict subsequent fractures independent of bone mineral density and other clinical risk factors, their recognition is an important part of strategies to identify those who are at high risk of fracture, so that prevention therapies for those individuals can be implemented. The 2007 Position Development Conference developed detailed guidelines regarding the indications for acquisition of, and interpretation and reporting of densitometric VFA tests. The purpose of the 2013 VFA Task Force was to simplify the indications for VFA yet keep them evidence based. The Task Force reviewed the literature published since the 2007 Position Development Conference and developed prediction models based on 2 large cohort studies (the Study of Osteoporotic Fractures and the Osteoporotic Fractures in Men Study) and the densitometry database of the University of Chicago. Based on these prediction models, indications for VFA were reduced to a simplified set of criteria based on age, historical height loss, use of systemic glucocorticoid therapy, and self-reported but undocumented prior vertebral fracture.     

带锁髓内钉治疗股骨干骨折失败原因分析及其对策

目的探讨带锁髓内钉治疗股骨干骨折失败的原因及其预防措施。方法1999年4月至2002年9月采用带锁髓内钉治疗股骨干骨折患者213例,其中失败18例。回顾性分析这18例患者的临床资料,并对其进行分类。结果18例患者中,按失败原因可分为断钉3例,其中主钉断裂2例,主钉合并远端锁钉断裂1例;远端锁钉退出7例;近端锁钉退出3例;膝关节纤维性强直3例;迟发感染2例。手术技术、手术适应证选择、康复锻炼的规范性、髓内钉的强度及合适与否是导致失败的相关原因。结论应用带锁髓内钉治疗股骨干骨折应掌握好适应证,强调术前准备充分,术中操作规范,术后锻炼应循序渐进,避免过早负重,是减少或防止内固定失效的重要措施。     

Patient characteristics and risk of subsequent contralateral hip fracture after surgical management of first fracture

Background

Sequential hip fractures are associated with increased morbidity and mortality. Understanding of risk factors is important for secondary prevention. Although hip fractures have a multifactorial aetiology related to falls, it is unknown whether fracture management approach influences the risk of sequential hip fractures.

Objectives

Our objective is to explore whether subsequent contralateral hip fractures are more common following femoral head replacement or salvage procedures for the treatment of hip fractures.

Methods

Patients older than 50, admitted to a single regional trauma unit in Worcestershire between 2010 and 2012 were identified from the national database. 700 patients matched our inclusion criteria and case notes were reviewed. The male to female ratio was 1:3.3 and the mean age was 82.8 years (standard deviation: 8.9 years). Contralateral fractures were identified from admission X-rays. Risk factors were analysed based on patient demographics and data related to first hip fracture management.

Results

Seventy-one patients presented with contralateral fractures, of which 19 had their first fracture during the data collection period, estimating a period prevalence of 10.1%, and incidence of 2.9%. Contralateral fracture rates were not significantly different between femoral head salvage and replacement procedures (P-value 0.683). Older institutionalised females with poorer mobility status were at greatest risk of contralateral hip fractures. Half (50.7%) of these occurred within 2 years of their first fracture.

Conclusion

No additional risk was seen in either fixation approaches. Risk factors identified were in keeping with existing literature, which can help to identify high-risk groups for targeted prevention strategies.     

Risk factors for periprosthetic femoral fracture

Periprosthetic femur fractures are associated with high patient morbidity and are difficult reconstructive challenges. Early identification and appropriate intervention are critical to prevent this complication. Studies varying from case reports to national arthroplasty registry databases have demonstrated that certain factors are associated with an increased risk of fracture. These include trauma, patient-specific problems, and technical issues related to the hip replacement itself. Recent evidence from large registries has shown that the key to prevention of periprosthetic femur fractures is routine follow-up with radiographic studies.     

上海地区骨质疏松性骨折的发病特点研究（附5923例分析）

目的 通过分析上海地区中老年人发生骨质疏松性骨折的部位、性别、年龄等,阐明该地区骨质疏松性骨折的发病特点,为骨质疏松性骨折的防治提供理论依据.方法 回顾2000年1月至2005年12月在我院因脆性骨折就诊的中老年患者5923例,按患者性别、年龄、骨折部位等进行归纳、分析及总结.结果 60岁以上女性骨折发生数明显多于男性,其中,常见部位骨折最高发生率的年龄分别为：桡骨远端骨折为70岁;股骨颈骨折为75岁;股骨粗隆间骨折为80岁.各年龄组女/男数据比较：60岁以后各年龄段的女/男值与总计中的女/男值1.96相比差异显著（P＜0.05）,表明按年龄段划分有统计学意义,60岁以后女性发生骨折的几率明显高于男性.结论 60岁以后女性骨折发生率明显多于男性,桡骨远端骨折、股骨颈骨折、股骨粗隆间骨折发病高峰的年龄各有不同,应在骨质疏松性骨折的防治中引起重视,并区别对待.