Traditional Chinese medicine for pressure ulcer: a meta‐analysis

To assess the effect of Traditional Chinese Medicine (TCM) [Chinese herbal medicine ointment (CHMO), acupuncture and moxibustion] on pressure ulcer. In this study, we searched MEDLINE, EMBASE, CENTER, CBM, CNKI, WAN FANG and VIP for articles published from database inception up to 4 April 2011. We included randomised controlled trials (RCTs), which compared the effects of TCM with other interventions. We assessed the methodological quality of these trials using Cochrane risk of bias criteria. Ten of 565 potentially relevant trails that enrolled a total of 893 patients met our inclusion criteria. All the included RCTs only used CHMO intervention, because acupuncture and moxibustion trials failed to meet the inclusive criteria. A meta‐analysis showed beneficial effects of CHMO for pressure ulcer compared with other treatments on the total effective rate [risk ratio (RR): 1·28; 95% confidence interval (CI): 1·20–1·36; P = 0·53; I² = 0%), curative ratio (RR: 2·02; 95% CI: 1·73–2·35; P = 0·11; I² = 37%) and inefficiency rate (RR: 0·16; 95% CI: 0·02–0·80; P = 0·84; I² = 0%). However, the funnel plot indicated that there was publication bias in this study. The evidence that CHMO is effective for pressure ulcer is encouraging, but due to several caveats, not conclusive. Therefore, more rigorous studies seem warranted.     

High inspired oxygen versus low inspired oxygen for reducing surgical site infection: a meta‐analysis

To perform a meta‐analysis of published literature to assess the role of high‐concentration inspired oxygen in reducing the incidence of surgical site infections (SSIs) following all types of surgery, a comprehensive search for published randomized controlled trials (RCTs) comparing high‐ with low‐concentration inspired oxygen for SSIs was performed. The related data were extracted by two independent authors. The fixed and random effects methods were used to combine data. Twelve RCTs involving 6750 patients were included. Our pooled result found that no significant difference in the incidence of SSIs was observed between the two groups, but there was high statistic heterogeneity across the studies [risk ratio (RR): 0·91; 95% confidence interval (CI): 0·72–1·14; P = 0·40; I² = 54%]. The sensitivity analysis revealed the superiority of high‐concentration oxygen in decreasing the SSI rate (RR: 0·86; 95% CI: 0·75–0·98; P = 0·02). Moreover, a subgroup analysis of studies with intestinal tract surgery showed that patients experienced less SSI when high‐concentration inspired oxygen was administrated (RR: 0·53; 95% CI: 0·37–0·74; P = 0·0003). Our study provided no direct support for high‐concentration inspired oxygen in reducing the incidence of SSIs in patients undergoing all types of surgery.     

Risk factors for venous thromboembolism following surgical treatment of fractures: A systematic review and meta-analysis

This study aimed to determine the risk factors for postoperative venous thromboembolism (VTE) in patients treated surgically for fractures using a meta-analytic approach. Electronic searches were performed in PubMed, Embase, and the Cochrane library from inception until February 2022. The odds ratio (OR) and 95% confidence interval (CI) were applied to calculate the pooled effect estimate using the random-effects model. Sensitivity, subgroup, and publication bias tests were also performed. Forty-four studies involving 3 239 291 patients and reporting 11 768 VTE cases were selected for the meta-analysis. We found that elderly (OR: 1.72; 95% CI: 1.38-2.15; P < .001), American Society of Anesthesiologists (ASA) ≥ 3 (OR: 1.82; 95% CI: 1.46-2.29; P < .001), blood transfusion (OR: 1.82; 95% CI: 1.14-2.92; P = .013), cardiovascular disease (CVD) (OR: 1.40; 95% CI: 1.22-1.61; P < .001), elevated D-dimer (OR: 4.55; 95% CI: 2.08-9.98; P < .001), diabetes mellitus (DM) (OR: 1.36; 95% CI: 1.19-1.54; P < .001), hypertension (OR: 1.31; 95% CI: 1.09-1.56; P = .003), immobility (OR: 3.45; 95% CI: 2.23-5.32; P < .001), lung disease (LD) (OR: 2.40; 95% CI: 1.29-4.47; P = .006), obesity (OR: 1.52; 95% CI: 1.27-1.82; P < .001), peripheral artery disease (PAD) (OR: 2.13; 95% CI: 1.21-3.73; P = .008), prior thromboembolic event (PTE) (OR: 5.17; 95% CI: 3.14-8.50; P < .001), and steroid use (OR: 2.37; 95% CI: 1.73-3.24; P < .001) were associated with an increased risk of VTE. Additionally, regional anaesthesia (OR: 0.66; 95% CI: 0.45-0.96; P = .029) was associated with a reduced risk of VTE following surgical treatment of fractures. However, alcohol intake, cancer, current smoking, deep surgical site infection, fusion surgery, heart failure, hypercholesterolemia, liver and kidney disease, sex, open fracture, operative time, preoperative anticoagulant use, rheumatoid arthritis, and stroke were not associated with the risk of VTE. Post-surgical risk factors for VTE include elderly, ASA ≥ 3, blood transfusion, CVD, elevated D-dimer, DM, hypertension, immobility, LD, obesity, PAD, PTE, and steroid use.     

Lifestyle interventions to prevent osteoporotic fractures: a systematic review

The purpose of this study was to evaluate the clinical effectiveness of lifestyle interventions for preventing osteoporotic fractures in people at high risk. Data sources were electronic bibliographic databases, reference lists of systematic reviews, meta-analyses and included trials, registers of trials and conference databases. There was no language restriction. Study selection comprised randomized controlled trials (RCTs), with appropriate comparator groups and at least 8 weeks of follow-up, reporting a fracture endpoint. Two reviewers independently abstracted data on the population, interventions evaluated, trial quality and outcomes of interest: fractures at any site, spinal, hip and wrist fractures. Six RCTs, enrolling over 1,656 participants, met the inclusion criteria. Overall, trials were of uncertain quality. We categorized trials by type of intervention: exercise ( n =3), multifactorial interventions (environmental modifications, exercise programs and review of medical conditions, medication and aids) ( n =2) and exposure to sunlight ( n =1), and used random effects meta-analyses to combine data within these categories. Exercise was associated with a non-significantly lower risk of spinal fractures (RR=0.52, 95% CI=0.17 to 1.60). Multifactorial interventions were associated with a lower risk of hip fracture, which was of borderline statistical significance (RR=0.37, 95% CI=0.13 to 1.03). Exposure to sunlight was associated with a non-significantly lower risk of hip fracture (RR=0.17, 95% CI=0.02 to 1.35). While withdrawals from treatment were poorly reported, there was no indication of adverse effects of treatment. Multifactorial interventions may reduce the risk of hip fractures when delivered by residential care staff and health visitors. More RCTs of higher quality, recording fractures at all sites susceptible to osteoporotic fractures, are necessary to evaluate exercise interventions, exposure to sunlight and the place of lifestyle alongside pharmacological interventions.     

Mortality Rates of Patients with a Hip Fracture in a Southwestern District of Greece: Ten-Year Follow-Up with Reference to the Type of Fracture

Increased mortality after a hip fracture has been associated with age, sex, and comorbidity. In order to estimate the long-term mortality with reference to hip fracture type, we followed 499 patients older than 60 years who had been treated surgically for a unilateral hip fracture for 10 years. At admission, patients with femoral neck fractures (n = 172) were 2 years younger than intertrochanteric patients (77.6 ± 7.7 [SD] vs. 79.9 ± 7.4 [SD], P = 0.001) and had a greater prevalence of heart failure (57% vs. 40.3%, P = 0.03). Similar mortality rates were observed at 1 year in both types of fracture (17.9% vs. 11.3%, log rank test P = 0.112). Mortality rates were significantly higher for intertrochanteric fractures at 5 years (48.8% vs. 34.7%, P = 0.01) and 10 years (76% vs. 58%, P = 0.001). Patients 60–69 years old with intertrochanteric fractures had significantly higher 10-year mortality than patients of similar age with femoral neck fractures (P = 0.008), while there was no difference between the groups aged 70–79 (P > 0.3) and 80–89 (P = 0.07). Women were less likely to die in 5 years (relative risk [RR] = 0.57, 95% confidence interval [CI] 0.41–0.79, P = 0.0007) and 10 years (RR = 0.65, 95% CI 0.49–0.85, P = 0.002). Age, sex, the type of fracture, and the presence of heart failure were independent predictors of 10-year mortality (Cox regression model P < 0.0001). The intertrochanteric type was independently associated with 1.37 (95% CI 1.03–1.83) times higher probability of death at 10 years (P = 0.002). In conclusion, the type of fracture is an independent predictor of long-term mortality in patients with hip fractures, and the intertrochanteric type yields worse prognosis.     

Length of surgery and pressure ulcers risk in cardiovascular surgical patients: a dose–response meta‐analysis

The aim of this study was to assess the relationship between length of surgery (LOS) and pressure ulcer (PU) risk in cardiovascular surgery patients. PubMed and Web of Science were systematically searched. We compared LOS difference between PU (+) group and PU (‐) group. We also examined the dose–response effect of this relationship. The mean LOS in the PU(+) groups ranged from 252·5 to 335·7 minutes, compared with 233·0 to 298·3 minutes in PU(?) groups. The LOS was higher in PU(+) groups compared with PU(?) groups [weighted mean difference (WMD) = 36·081 minutes; 95% CI: 21·640–50·522 minutes; Z = 4·90, P = 0·000]. The funnel plot showed no publication bias. A significant dose–response association was also found between the LOS and the risk of surgery‐related pressure ulcers (SRPU, model χ² = 9·29, P = 0·000). In the linear model, the PU OR was 1·296 (95% CI 1·097–1·531) for a 60‐minute increase in the LOS intervals and 13·344 (95% CI 2·521–70·636) for a 600‐minute increase. In a spline model, the OR of PU increased almost linearly along with the LOS. Our meta‐analysis indicated that LOS was an important risk factor for pressure ulcers in cardiovascular surgical patients.     

Mediastinitis after coronary artery bypass grafting increases the incidence of left internal mammary artery obstruction

Mediastinitis after coronary artery bypass grafting (CABG) gives a longstanding chronic inflammation and has a detrimental negative effect on long‐term survival. For this reason, we aimed to study the effect of mediastinitis on graft patency after CABG. The epidemiologic design was of an exposed (mediastinitis, n = 41) versus non‐exposed (non‐mediastinitis, controls, n = 41) cohort with two endpoints: (i) obstruction of saphenous vein grafts (SVG) and (ii) obstruction of the internal mammary artery (IMA) grafts. The graft patency was evaluated with coronary CT‐angiography examination at a median follow‐up of 2·7 years. The number of occluded SVG in the mediastinitis group was 18·9% versus 15·5% in the control group. Using generalized estimating equations model with exchangeable matrix, and confounding effect of ischaemic time and patients age, we found no significant association between presence of mediastinitis and SVG obstruction [rate ratio (RR) = 0·96, 95% CI (0·52–2·67), P = 0·697]. The number of occluded IMA grafts was 10·5% in the mediastinitis group and 2·4% in the control group. Using the Poisson regression model, we estimated RR = 5·48, 95% CI (1·43–21·0) and P = 0·013. There was a significant association between mediastinitis and IMA graft obstruction, when controlling for the confounding effect of ischaemic time, body mass index, presence of diabetes mellitus and the number of diseased vessels. Presence of mediastinitis increases the risk of IMA graft obstruction. This may confirm the importance of inflammation as a major contributor to the pathogenesis of atherosclerosis and explain the negative effect of mediastinitis on a long‐term survival.     

Predicting complex acute wound healing in patients from a wound expertise centre registry: a prognostic study

It is important for caregivers and patients to know which wounds are at risk of prolonged wound healing to enable timely communication and treatment. Available prognostic models predict wound healing in chronic ulcers, but not in acute wounds, that is, originating after trauma or surgery. We developed a model to detect which factors can predict (prolonged) healing of complex acute wounds in patients treated in a large wound expertise centre (WEC). Using Cox and linear regression analyses, we determined which patient‐ and wound‐related characteristics best predict time to complete wound healing and derived a prediction formula to estimate how long this may take. We selected 563 patients with acute wounds, documented in the WEC registry between 2007 and 2012. Wounds had existed for a median of 19 days (range 6–46 days). The majority of these were located on the leg (52%). Five significant independent predictors of prolonged wound healing were identified: wound location on the trunk [hazard ratio (HR) 0·565, 95% confidence interval (CI) 0·405–0·788; P = 0·001], wound infection (HR 0·728, 95% CI 0·534–0·991; P = 0·044), wound size (HR 0·993, 95% CI 0·988–0·997; P = 0·001), wound duration (HR 0·998, 95% CI 0·996–0·999; P = 0·005) and patient's age (HR 1·009, 95% CI 1·001–1·018; P = 0·020), but not diabetes. Awareness of the five factors predicting the healing of complex acute wounds, particularly wound infection and location on the trunk, may help caregivers to predict wound healing time and to detect, refer and focus on patients who need additional attention.     

The Comparison between Cemented and Uncemented Hemiarthroplasty in Patients with Femoral Neck Fractures: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

Hemiarthroplasty is the standard treatment for patients with femoral neck fractures (FNFs). Controversy exists over the use of bone cement in hip fractures treated with hemiarthroplasty.

Objective

We performed an updated systematic review and meta-analysis to compare cemented and uncemented hemiarthroplasty in patients with femoral neck fractures.

Methods

A literature review was conducted using Cochrane Library, ScienceDirect, PubMed, Embase, Medline, Web of Science, CNKI, VIP, Wang Fang, and Sino Med databases. Studies comparing cemented with uncemented hemiarthroplasty for FNFs in elderly patients up to June 2022 were included. Data were extracted, meta-analyzed, and pooled as risk ratios (RRs) and weighted mean differences (WMDs) with a 95% confidence interval (95% CI).

Results

Twenty-four RCTs involving 3471 patients (1749 cement; 1722 uncemented) were analyzed. Patients with cemented intervention had better outcomes regarding hip function, pain, and complications. Significant differences were found in terms of HHS at 6 weeks (WMD 12.5; 95% CI 6.0–17.0; P < 0.001), 3 months (WMD 3.3; 95% CI 1.6–5.0; P < 0.001), 4 months (WMD 7.3; 95% CI 3.4–11.2; P < 0.001), and 6 months (WMD 4.6; 95% CI 3.3–5.8; P < 0.001) postoperatively. Patients with cemented hemiarthroplasty had lower rates of pain (RR 0.59; 95% CI 0.39–0.9; P = 0.013), prosthetic fracture (RR 0.24; 95% CI 0.16–0.38; P < 0.001), subsidence/loosening (RR 0.29; 95% CI 0.11–0.78; P = 0.014), revisions (RR 0.59; 95% CI 0.40–0.89; P = 0.012), and pressure ulcers (RR 0.43; 95% CI 0.23–0.82; P = 0.01) at the expense of longer surgery time (WMD 7.87; 95% CI 5.71–10.02; P < 0.001).

Conclusion

This meta-analysis demonstrated that patients with cemented hemiarthroplasty had better results in hip function and pain relief and lower complication rates at the expense of prolonged surgery time. Cemented hemiarthroplasty is recommended based on our findings.     

Risk factors for hip fractures in a middle-aged population: a study of 33,000 men and women

Knowledge about subjects who sustain hip fractures in middle age is poor. This study prospectively investigated risk factors for hip fracture in middle age and compared risk factors for cervical and trochanteric hip fractures. The Malmö Preventive Project consists of 22,444 men, mean age 44 years, and 10,902 women, mean age 50 years at inclusion. Baseline assessment included multiple examinations and lifestyle information. Follow-up was up to 16 years with regard to occurrence of fracture. One hundred thirty-five women had one low-energy hip fracture each, 93 of which were cervical and 42 trochanteric. One hundred sixty-three men had 166 hip fractures, of which 81 were cervical and 85 trochanteric. In the final Cox regression model for women, the risk factors with the strongest associations with hip fracture were diabetes (risk ratio (RR) 3.89, 95% confidence interval (CI) 1.69–8.93, p =0.001) and poor self-rated health (RR 1.74, 95%CI 1.22–2.48, p =0.002). A history of previous fracture (RR 4.76, 95%CI 2.74–8.26, p =0.0001) was also a significant risk factor. In men, diabetes had the strongest association with hip fracture (RR 6.13, 95%CI 3.19–11.8, p =0.001). Smoking (RR 2.20, 95%CI 1.54–3.15, p =0.001), high serum -glutamyl transferase (RR 1.84, 95%CI 1.50–2.26, p =0.001), poor self-rated health (RR 1.49, 95%CI 1.06–2.10, p =0.02) and reported sleep disturbances (RR 1.52, 95%CI 1.03–2.27, p =0.04) were other significant risk factors. The strongest risk factor for hip fracture for both women and men in middle age was diabetes. Many risk factors were similar for men and women, although the risk ratio differed. The risk factor pattern for cervical versus trochanteric fractures differed in both men and women. The findings indicate that those suffering a hip fracture before the age of 75 have a shorter life expectancy, suggesting that hip fractures affect the less healthy segment of the population.     

Risk Factors for Perimenopausal Fractures: A Prospective Study

This prospective study was aimed at determining the risk factors for the development of fractures in perimenopausal women. The study group (n= 3068) was comprised of a stratified population sample of women aged between 47 and 56 years. During the follow-up period of 3.6 years, 257 (8.4%) of the women sustained a total of 295 fractures. After adjustment for covariates, the relative risk (RR) of sustaining a fracture was found to be 1.4 [95% confidence interval (CI) 1.2–1.6] for a 1 standard deviation (SD) decrease in the spinal and femoral neck bone mineral density (BMD). Women with a previous fracture history were found to have an increased risk of fracture [RR 1.7 (95% CI 1.3–2.2)] and those reporting three or more chronic illnesses exhibited a RR of 1.4 (95% CI 1.0–1.9). Women not using hormone replacement therapy (HRT) had a RR of 1.5 (95% CI 1.1–2.2) for all fracture types. When osteoporotic fractures (vertebral, hip, proximal humerus and wrist fractures; n= 98) were used as an endpoint, the independent risk factors were found to be a low BMD (RR for a 1 SD decrease in both spinal and femoral neck BMD was 1.6, 95% CI 1.3–2.0), a previous fracture history (RR 1.9, 95% CI 1.3–2.9) and nonuse of HRT (RR 2.2, 95% CI 1.3–4.0). The independent risk factors for all other fractures (n = 158) were a low BMD (RR for a 1 SD decrease in the spinal BMD was 1.4, 95% CI 1.2–1.6 and in the femoral neck BMD was 1.3, 95% CI 1.1–1.5), a previous fracture history (RR 1.6, 95% CI 1.1–2.2), smoking (RR 1.8, 95% CI 1.1–2.7) and having had three or more chronic illnesses (RR 1.6, 95% CI 1.1–2.2). Weight, height, age, menopausal status, maternal hip fracture, use of alcohol, coffee consumption or dietary calcium intake were not independently associated with the development of any particular type of fracture. We conclude that the independent risk factors for perimenopausal fractures are a low bone density, previous fracture history, nonuse of HRT, having had three or more chronic illnesses and smoking, the gradient of risk being similar for spinal and femoral neck BMD measurements in the perimenopausal population. The risk factors are slightly different for perimenopausal osteoporotic than for other types of fractures. Received: 6 April 1999 / Accepted: 18 August 1999     

Systemic factors and mortality in elderly patients with pressure ulcers

The aim of this article was to identify specific systemic factors associated with existence of pressure ulcers (PUs) and the effect on survival from the time of admission. Patients admitted to the Skilled Nursing Department of the Herzog Hospital, Jerusalem, between 1 July 2008 and 31 December 2011. Of the 174 admitted patients (mean age: 77·4 ± 13·2 years), 107 (61·5%) had pre‐existing PUs and 67 (38·5%) did not have PUs. Major systemic factors were assessed for each patient at the time of admission: sociodemographic characteristics, comorbidities, use of urinary catheter, tube feeding and tracheostomy; nutritional state; Global Deterioration Scale, Glasgow Coma Scale and Norton Scale. Complications such as the number of provided antibiotic courses, and length and outcomes of hospitalisation were identified at the end of the study. In the univariate analysis, patients in the PU group had significantly prevalent characteristics including advanced age, low cognitive and consciousness function, low Norton scale, Parkinson's disease and anaemia due to chronic diseases, low nutritional parameters and higher number of antibiotics provided. Conditions that were associated with PUs in multiple regression analyses included advanced dementia (OR = 3·0, 95% CI: 1·4–6·3; P = 0·002), urinary catheter usage (OR = 2·25, 95% CI: 1·06–4·7; P = 0·03), low body mass index, BMI (OR = 0·92, 95% CI: 0·86–0·99; P = 0·02) and anaemia level (OR = 0·7, 95% CI: 0·58–0·9; P = 0·004). The median survival time of patients with PUs was significantly lower than the non PUs group (94 versus 414 days, respectively) (P = 0·005, log rank test). Length of stay was also significantly lower in the PU group (166 versus 270 days, P = 0·02). The existence of PUs may indicate a final common pathway of various systemic factors (geriatric conditions, diseases and frailty dysfunction).     

Total hip replacement after femoral neck fractures in elderly patients : Results of 8,577 fractures reported to the Norwegian Arthroplasty Register

Background?A total hip arthroplasty (THA) is often used as treatment for failed osteosynthesis of femoral neck fractures and is now also used for acute femoral neck fractures. To investigate the results of THA after femoral neck fractures, we used data from the Norwegian Arthroplasty Register (NAR).

Patients and methods?The results of primary total hip replacements in patients with acute femoral neck fractures (n = 487) and sequelae after femoral neck fractures (n = 8,090) were compared to those of total hip replacements in patients with osteoarthrosis (OA) (n = 55,109). The hips were followed for 0–18 years. The Cox multiple regression model was used to construct adjusted survival curves and to adjust for differences in sex, age, and type of cement among the diagnostic groups. Separate analyses were done on the subgroups of patients who were operated with Charnley prostheses.

Results?The survival rate of the implants after 5 years was 95% for the patients with acute fractures, 96% for the patients with sequelae after fracture, and 97% for the OA patients. With adjustment for age, sex, and type of cement, the patients with acute fractures had an increased risk of revision compared to the OA patients (RR 1.6, 95% CI: 1.0–2.6; p = 0.05) and the sequelae patients had an increased risk of revision (RR 1.3, 95% CI: 1.2–1.5; p < 0.001). Sequelae hips had higher risk of revision due to dislocation (RR 2.0, 95% CI: 1.6–2.4; p < 0.001) and periprosthetic fracture (RR 2.2, 95% CI: 1.5–3.3; p < 0.001), and lower risk of revision due to loosening of the acetabular component (RR 0.72, 95% CI; 0.57–0.93; p = 0.01) compared to the OA patients. The increased risk of revision was most apparent for the first 6 months after primary operation.

Interpretation?THA in fracture patients showed good results, but there was an increased risk of early dislocations and periprosthetic fractures compared to OA patients.     

Associations of hyperuricemia,gout, and UA-lowering therapy with the risk of fractures: A meta-analysis of observational studies

ObjectiveA systematic review and meta-analysis were conducted to investigate the associations of hyperuricemia, gout, and uric acid (UA)-lowering therapy with the risk of fractures.MethodsElectronic searches on PubMed, the Cochrane Library, and Embase were conducted from inception to January 2, 2019. Observational studies assessing the effects of hyperuricemia, gout, and UA-lowering therapy on fractures were included in the meta-analysis. Summary risk estimates with 95% confidence intervals (CI) were calculated by a random-effects model.ResultsA total of 14 eligible studies with 909 803 participants and 64 047 incident fractures were included. The results suggested that hyperuricemia and gout are not associated with any type of fracture (relative risk [RR], 0.98, 95% CI 0.85–1.11; P = 0.71) or osteoporotic fractures (RR, 1.02, 95% CI 0.90–1.14; P = 0.79). Further analysis indicated that hyperuricemia is associated with a lower risk of fractures (RR, 0.80, 95% CI 0.66–0.96; P = 0.02) but not with osteoporotic fractures (RR, 0.84, 95% CI 0.68–1.03; P = 0.10). However, gout is associated with an increased risk of fractures (RR, 1.17, 95% CI 1.04–1.31; P = 0.007) as well as osteoporotic fractures (RR, 1.13, 95% CI 1.00–1.26; P = 0.045). Furthermore, no significant association of UA-lowering therapy with the risk of fractures was found compared with the placebo (RR, 0.88, 95% CI 0.76–1.03; P = 0.11). Evidence supporting a non-linear association between serum UA levels and fractures was found (P < 0.001 for non-linearity), which revealed a U-shaped curve.ConclusionOur meta-analysis revealed that hyperuricemia was associated with lower risk for any type fracture but not associated with osteoporotic fractures; however, gout was associated with an increased risk of any type fracture as well as osteoporotic fractures. Notably, a U-shaped relationship may exist between the serum UA level and fractures. The associations observed in our study may be due to reasons other than causality.     

The association between fracture site and obesity in men: A population‐Based cohort study

A site‐dependent association between obesity and fracture has been reported in postmenopausal women. In this study we investigated the relationship between body mass index (BMI) and fracture at different skeletal sites in older men (≥65 years). We carried out a population‐based cohort study using data from the Sistema d‘Informació per al Desenvolupament de l‘Investigació en Atenció Primària (SIDIAP^Q) database. SIDIAP^Q contains the primary care and hospital admission computerized medical records of >1300 general practitioners (GPs) in Catalonia (Northeast Spain), with information on a representative 30% of the population (>2 million people). In 2007, 186,171 men ≥65 years were eligible, of whom 139,419 (74.9%) had an available BMI measurement. For this analysis men were categorized as underweight/normal (BMI < 25 kg/m², n = 26,298), overweight (25 ≤ BMI < 30 kg/m², n = 70,851), and obese (BMI ≥ 30 kg/m², n = 42,270). Incident fractures in the period 2007 to 2009 were ascertained using International Classification of Diseases, 10th edition (ICD‐10) codes. A statistically significant reduction in clinical spine and hip fractures was observed in obese (relative risk [RR], 0.65; 95% confidence interval [CI], 0.53–0.80 and RR, 0.63; 95% CI, 0.54–0.74, respectively), and overweight men (RR, 0.77; 95% CI, 0.64–0.92 and RR, 0.63; 95% CI 0.55–0.72, respectively) when compared with underweight/normal men. Additionally, obese men had significantly fewer wrist/forearm (RR, 0.77; 95% CI, 0.61–0.97) and pelvic (RR, 0.44; 95% CI, 0.28–0.70) fractures than underweight/normal men. Conversely, multiple rib fractures were more frequent in overweight (RR, 3.42; 95% CI, 1.03–11.37) and obese (RR, 3.96; 95% CI, 1.16–13.52) men. In this population‐based cohort of older men, obesity was associated with a reduced risk of clinical spine, hip, pelvis, and wrist/forearm fracture and increased risk of multiple rib fractures when compared to normal or underweight men. Further work is needed to identify the mechanisms underlying these associations.     

Soft silicone foam dressing is more effective than polyurethane film dressing for preventing intraoperatively acquired pressure ulcers in spinal surgery patients: the Border Operating room Spinal Surgery (BOSS) trial in Japan

Preventing intraoperatively acquired pressure ulcers (IAPUs) in patients undergoing spinal surgery in the prone position using a Relton‐Hall frame is challenging. We investigated the efficacy of soft silicone foam dressings in preventing IAPUs. A prospective dual‐center sham study was conducted among patients undergoing elective spinal surgery in a general hospital and a university hospital in Japan. The incidence of IAPUs that developed when soft silicone foam dressings and polyurethane film dressings were used was compared on two sides in the same patient. IAPUs developed on the chest in 11 of 100 patients (11%). Polyurethane film dressings were associated with a significantly higher rate of IAPUs than soft silicone foam dressings (11 versus 3, P = 0·027). A multivariate logistic regression analysis revealed that a diastolic blood pressure of <50 mmHg (P = 0·025, OR 3·74, 95% confidence interval [CI] 1·18–13·08) and the length of surgery (by 1 hour: P = 0·038, OR 1·61, 95% CI 1·03–2·64) were independently associated with the development of IAPUs. The use of soft silicone foam dressings reduced the risk of IAPUs (P = 0·019, OR 0·23, 95% CI 0·05–0·79) and was more effective than film dressings for preventing IAPUs in spinal surgery patients.     

A meta-analysis of the Gamma nail and dynamic hip screw in treating peritrochanteric fractures

The objective of this meta-analysis was to compare the fixation outcome of the Gamma nail and dynamic hip screw (DHS) in treating peritrochanteric fractures. Relevant randomised controlled studies were included, and the search strategy followed the requirements of the Cochrane Library Handbook. Methodological quality was assessed and data were extracted independently. Seven studies involving 1,257 fractures were included which compared the effect of the Gamma nail and DHS. The results showed a higher rate of postoperative femoral shaft fracture with the Gamma nail compared to the DHS [relative risk (RR): 7.27, 95% confidence interval (CI): 2.83–18.70, P < 0.0001] but no statistical differences in wound infection (RR: 1.02, 95% CI: 0.56–1.86), mortality (RR: 1.00, 95% CI: 0.81–1.24), re-operation (RR: 1.64, 95% CI: 0.91–2.95) and walking independently after rehabilitation (RR: 0.89, 95% CI: 0.60–1.33). It seemed that there were no obvious advantages of the Gamma nail over the DHS in treating peritrochanteric fractures.     

Quantitative Ultrasound and Bone Densitometry to Evaluate the Risk of Nonspine Fractures: A Prospective Study

The ability of quantitative ultrasound (QUS) to estimate the risk of osteoporotic fractures was evaluated in a prospective study over a mean time of 5.47 years in 254 postmenopausal women (mean age 58.06 ± 7.67 years). Baseline measurements of ultrasound transmission velocity (UTV) and bone mineral density (BMD) were taken at the distal radius (DR). UTV was also measured at the patella (P). Fifty nonspine fractures due to minor trauma were detected during annual check-ups with an incidence of 3.59/year. Fractures occurred in older women with a lower BMD and QUS. Using Cox regression analysis the relative risk (RR) per 1 standard deviation (SD) decrease in the unadjusted QUS and BMD measurements was: BMD-DR = 3.56, 95% confidence interval (CI) 1.57–8.09; UTV-DR = 5.35, 95% CI 2.07–13.83; UTV-P = 4.49, 95% CI 2.08–9.68. The relationship between BMD and QUS variables and fracture risk persisted after adjusting for potential confounders apart from previous fractures, giving the following RR: BMD-DR = 2.99, 95% CI 1.06–8.41; UTV-DR = 3.69, 95% CI 1.18–11.49; UTV-P = 3.89, 95% CI 1.53–9.90. Correcting also for previous fractures, only UTV-P remained an effective predictor of fracture risk even after QUS measurement correction for BMD. Wrist fractures were best related to BMD-DR (RR 7.33, 95% CI 1.43–37.50) and UTV-DR (RR 10.94, 95% CI 1.10–108.45), while hip and ankle fractures were significantly associated only with UTV-P (hip: RR 32.14, 95% CI 1.83–562.80; ankle: RR 17.60, 95% CI 1.78–173.79). The combined use of BMD and QUS is a better predictor of fracture risk than either technique used separately. Comparison of the areas under the receiver operating characteristic (ROC) curves did not show differences in the ability of BMD and QUS to correctly distinguish fractures. In conclusion, QUS predicts fracture risk in osteoporotic women at least as well as BMD. UTV-DR and BMD-DR are good predictors of wrist fractures, while UTV-P is strongly related to hip and ankle fractures. QUS and BMD combined improve the diagnostic ability of each technique individually. Received: 27 April 1999 / Accepted: 3 December 1999     

High energy injury is a risk factor for preoperative venous thromboembolism in the patients with hip fractures: A prospective observational study

BackgroundThe purpose of this study was to identify the incidence of preoperative venous thromboembolism (VTE), and determine if high energy hip fracture affects preoperative VTE occurrence.MethodsThree-hundred nine patients (244 low and 61 high energy injuries) treated between March 2015 and March 2017 were included in this study. Indirect multidetector computed tomographic venography for the detection of preoperative VTE was performed at admission. The incidence of preoperative VTE was compared between high and low energy injury hip fractures. Logistic regression analysis was used to identify independent risk factors for preoperative VTE.ResultsThe overall incidence of preoperative VTE was 18.4% (56 of 305 patients). Preoperative VTE was identified in 17 (27.9%) and 39 (16.0%) patients in the high and low energy injury groups, respectively (p = 0.034). Multivariate logistic regression analysis showed that high energy injury, history of VTE, and myeloproliferative disease were significant predictive factors of preoperative VTE (OR = 2.451; 95% CI = 1.227–4.896, OR = 11.174; 95% CI = 3.500–35.673, OR = 6.936; 95% CI = 1.641–29.321, respectively)ConclusionBecause high energy hip fracture is significantly associated with preoperative VTE occurrence, preoperative evaluation and proper thromboprophylaxis should be performed for patients with a high-energy hip fracture.     

Effect of alendronate on the age-specific incidence of symptomatic osteoporotic fractures.

Analyses of data from 3658 postmenopausal women with osteoporosis enrolled in the Fracture Intervention Trial showed that alendronate is effective in reducing the risk of symptomatic osteoporotic fractures across a spectrum of ages. INTRODUCTION: Most osteoporosis studies examine the relative risk of fracture based on the entire duration of treatment. Because older patients tend to be at higher risk for osteoporosis-related fractures, this analysis examined the effect of alendronate treatment on the relative risk of fracture in terms of the age that patients attained during the study. MATERIALS AND METHODS: We studied 3658 postmenopausal women with osteoporosis 55-80 years of age at baseline enrolled in the Fracture Intervention Trial, a large randomized, double-blind, placebo-controlled study. Patients were treated with placebo or with alendronate at a daily dose of 5 mg for 2 years followed by 10 mg for an additional 1-2.5 years, and monitored for clinical fractures. Age, rather than study time, was the dynamic variable in our analysis. RESULTS: The relative risk reductions for hip, clinical spine, and wrist fractures were constant across age groups, without evidence of a decline at older ages. Specifically, alendronate reduced the risk of clinical fracture by 53% at the hip (relative risk [RR] = 0.47; 95% CI = 0.27-0.81; p < 0.01), 45% at the spine (RR = 0.55; 95% CI = 0.37-0.83; p < 0.01), and 31% at the wrist (RR = 0.69; 95% CI = 0.50-0.98; p = 0.038). In addition, alendronate produced a significant risk reduction of 40% (RR = 0.60; 95% CI = 0.47-0.77; p < 0.01) for the composite event of clinical hip, spine, and wrist fractures. As a consequence of the constant relative risk model, the absolute risk reduction with alendronate treatment increased with age because of the age-related increase in fracture risk in the placebo group. The absolute risk reduction for the composite event (hip, spine, and wrist fractures together) for alendronate treatment versus placebo was 65, 80, 111, and 161 women with fractures per 10,000 PYR for the 55 to <65, 65 to <70, 70 to <75, and 75-85 year age groups, respectively. CONCLUSIONS: These data show that alendronate is effective in reducing the risk of symptomatic osteoporotic fractures across a spectrum of ages. The effectiveness is somewhat greater in patients with femoral neck T score < or = -2.5 than in those with a T score < or = -2.0.