Survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association.

A survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association conducted in 2022 found considerable variation in care across the region. A Call to Action is proposed to improve acute care, rehabilitation and secondary fracture prevention across Asia Pacific. PURPOSE: Fragility fractures impose a substantial burden on older people and their families, healthcare systems and national economies. The current incidence of hip and other fragility fractures across the Asia Pacific region is enormous and set to escalate rapidly in the coming decades. This publication describes findings of a survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association (APOA) conducted in 2022. METHODS: The survey was developed as a collaboration between the Asia Pacific Osteoporosis and Fragility Fracture Society and the Asia Pacific Fragility Fracture Alliance, and included questions relating to aspects of care upon presentation, during surgery and mobilisation, secondary fracture prevention, and access to specific services. RESULTS: In total, 521 APOA members completed the survey and marked variation in delivery of care was evident. Notable findings included: Fifty-nine percent of respondents indicated that analgesia was routinely initiated in transit (by paramedics) or within 30 minutes of arrival in the Emergency Department. One-quarter of respondents stated that more than 80% of their patients underwent surgery within 48 hours of admission. One-third of respondents considered non-hip, non-vertebral fractures to merit assessment of future fracture risk. One-third of respondents reported the presence of an Orthogeriatric Service in their hospital, and less than a quarter reported the presence of a Fracture Liaison Service. CONCLUSION: A Call to Action for all National Orthopaedic Associations affiliated with APOA is proposed to improve the care of fragility fracture patients across the region.

Predictive Model of Recovery to Prefracture Activities-of-Daily-Living Status One Year after Fragility Hip Fracture.

Background and Objectives: Achieving prefracture functional status is a critical objective following a hip fracture, yet fewer than half of patients reach this milestone. The adoption of tools for assessing functional outcomes is increasingly recognized as essential for evaluating recovery following treatment for fragility hip fractures. We developed multivariable clinical prediction criteria to estimate the likelihood of patients regaining their prefracture activities-of-daily-living (ADL) status one year after sustaining a fragility hip fracture. Materials and Methods: A retrospective cohort of patients treated for fragility hip fractures at a university-affiliated tertiary care center between February 2017 and April 2019 served as the basis for developing and internally validating the clinical prediction criteria. We applied a multivariable fractional polynomial method to integrate several continuous predictors into a binary logistic regression model. Results: The study included 421 patients, 324 (77%) of whom reported regaining their prefracture activities-of-daily-living level one year after experiencing fragility hip fractures. Significant predictors, such as the prefracture Barthel index, EQ-VAS score, and treatment modality, were incorporated into the predictive model. The model demonstrated excellent discriminative power (AuROC of 0.86 [95% CI 0.82-0.91]) and satisfactory calibration. Conclusions: The predictive model has significant discriminative ability with good calibration and provides clinicians with a means to forecast the recovery trajectories of individual patients one year after a fragility hip fracture, which could be useful because prompt clinical decision-making is aided by this information. Patients and caregivers can also be counseled and encouraged to follow up with the medical activities and interventions deemed essential by doctors who used the prediction tool. Access to the model is provided through a web application. External validation is warranted in order to prove its applicability and generalizability.

Prevalence of osteoporosis, sarcopenia, and high falls risk in healthy community-dwelling Thai older adults: a nationwide cross-sectional study.

Thailand has transitioned from an aging society to an aged society, which implies that the prevalence of age-related disorders will increase; however, epidemiological data specific to the prevalence of age-related degenerative musculoskeletal disorders among Thai older adults remain limited. Accordingly, the aim of this study was to investigate the prevalence of age-related musculoskeletal diseases, including osteoporosis, sarcopenia, and high falls risk among healthy community-dwelling Thai older adults. This cross-sectional nationwide study enrolled Thai adults aged ≥60 yr from 2 randomly selected provinces from each of the 6 regions of Thailand via stratified multistage sampling during March 2021 to August 2022. All enrolled participants were evaluated for BMD, skeletal muscle mass, grip strength, and gait speed. Osteoporosis was diagnosed according to the World Health Organization definition, and sarcopenia was diagnosed according to the Asian Working Group for Sarcopenia (AWGS) 2019 criteria. Falls risk was determined using the self-rated Fall Risk Questionnaire. A total of 2991 eligible participants were recruited. The mean age of participants was 69.2 ± 6.5 yr (range: 60-107), and 63.1% were female. The prevalence of osteoporosis, sarcopenia, and high falls risk was 29.7%, 18.1%, and 38.5%, respectively. Approximately one-fifth of subjects (19.1%) had at least 2 of 3 risk factors (ie, osteoporosis, sarcopenia, and high falls risk) for sustaining a fragility fracture, and 3.4% had all 3 risk factors. In conclusion, the results of this study revealed a high and increasing prevalence of osteoporosis, sarcopenia, and high falls risk in healthy community-dwelling Thai older adults. Since these conditions are all major risk factors for fragility fracture, modification of Thailand's national health care policy is urgently needed to address the increasing prevalence of these conditions among healthy community-dwelling older adults living in Thailand.

Prognostic Factors for Functional Recovery at 1-Year Following Fragility Hip Fractures.

Background: The main objective of treating fragility hip fractures is to maximize the patients' ability to return to their basic activities of daily living (ADL) levels. This study explored prognostic factors associated with the ability to recover pre-fracture ADL levels at 1 year after fragility hip fractures. Methods: We retrospectively recruited patients admitted with fragility hip fractures between July 2016 and September 2018. Details of the following were extracted from electronic medical records: age, sex, body mass index; pre-fracture Charlson Comorbidity Index (CCI), Barthel index, and EuroQol-Visual Analog Scale (EQ-VAS) scores; pre-fracture ambulatory status; and fracture type and treatment. The primary endpoint was the ability to return to the pre-fracture ADL status at 1 year. Multivariable logistic regression analysis assessed the prognostic ability of predictors. Results: Of 405 patients, 284 (70.1%) managed to return to their pre-fracture ADL status. Multivariable logistic regression analysis demonstrated that the predictor with the most apparent effect size was pre-fracture EQ-VAS scores ≥ 65 (multivariable odds ratio [mOR], 12.90; p = 0.03). Other influential predictors were CCI scores < 5 (mOR, 1.96; p = 0.01) and surgical treatment for the hip fracture. Conclusions: Three prognostic factors can predict a hip fracture patient's ability to return to the pre-fracture ambulatory status at 1 year. They are the patient's CCI score, operative treatment for the hip fracture, and the pre-fracture EQ-VAS score. This information could be used to develop a clinical prediction model based on the prognostic factors.

Establishing Normative Values for Performance-Based Tests in Older Thai Adults: A Nationwide Cross-Sectional Study.

OBJECTIVE: To determine normative values and identify contributing factors for physical performance tests in older, Thai, community-dwelling adults. DESIGN: Nationwide cross-sectional study. SETTING: Thai older community-dwelling adults. PARTICIPANTS: Thai older community-dwelling adults aged ≥60 years who had no major health problems (N=1430) between March 2021 and August 2022. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Normative values for the timed Up and Go (TUG) test, gait speed test, and 5-times sit-to-stand (5TSTS) test were determined for sex and age groups. Multivariable quantile regression analysis was employed to evaluate the participants, considering factors that may influence physical performance, such as height, and Charlson comorbidity index (CCI). RESULTS: The study included 1430 eligible participants. Their mean age was 68.4±5.8 years, and 58.5% were women. Men demonstrated superior physical performance in the medians (p50) of the TUG (10.0 s vs 11.0 s), gait speed (0.98 m/s vs 0.91 m/s), and 5TSTS (14.0 s vs 16.1 s) tests compared with women. These differences were consistently observed across age groups. Moreover, age, sex, and height were significantly associated with poor physical performance. CONCLUSION: This study observed variations in the normative values of TUG, gait speed, and 5TSTS tests among different age groups of older, Thai, community-dwelling adults. Additionally, our findings identified age, sex, and height as significant contributing factors to physical performance in this population.

Sarcopenia in Thai community-dwelling older adults: a national, cross-sectional, epidemiological study of prevalence and risk factors.

BACKGROUND: Sarcopenia is an age-related condition characterized by a progressive loss of skeletal muscle mass. It leads to declining physical performance, potentially culminating in a diminished quality of life or death. This study investigated the prevalence of sarcopenia and its associated risk factors among Thai community-dwelling individuals of advanced age. METHODS: Between March 2021 and August 2022, we conducted a nationwide community-based epidemiological survey across all six major regions of Thailand. Participants with sarcopenia were identified according to the 2019 criteria of the Asian Working Group for Sarcopenia (AWGS). The risk factors were examined using multivariable logistic regression. RESULTS: Of the 2456 participants, the overall prevalence of sarcopenia was 18.1%, with nearly two-thirds (66.9%) classified as having severe sarcopenia. Multivariate analysis identified six associated risk factors for sarcopenia. They are a lower body mass index (odds ratio [OR] = 11.7, 95% confidence interval [CI] = 7.8-17.4), suboptimal leg calf circumference (OR = 6.3, 95% CI = 4.3-9.5), male sex (OR = 2.8, 95% CI = 2.2-3.7), a history of chronic obstructive pulmonary disease (OR = 2.3, 95% CI = 2.3-5.0), advanced age (OR = 2.1, 95% CI = 1.3-3.3), and an increasing time in the timed up-and-go test (OR = 1.1, 95% CI = 1.0-1.1). CONCLUSIONS: This is the first large-scale national study to represent the prevalence and risk factors for sarcopenia in Thai community-dwelling individuals of advanced age using the AWGS 2019 criteria. Interventions such as lifestyle modifications and appropriate nutrition should be promoted throughout adulthood to maintain muscle strength and delay the onset of sarcopenia, particularly in males. TRIAL REGISTRATION: The Central Research Ethics Committee of the National Research Council of Thailand authorized the study protocol (approval number COA-CREC023/2021).

A multidisciplinary approach to post-operative fragility hip fracture care in Thailand - a narrative review.

INTRODUCTION: Appropriate care and rehabilitation following surgery for fragility hip fractures in older adults is associated with better outcomes and a greater likelihood of achieving pre-injury functioning. Clinical guidelines specifically for the post-operative care and rehabilitation of patients with hip fractures are scarce; as such, country-specific protocols benchmarked against established guidelines are essential given the wide variation in cultures and beliefs, clinical practice and diverse healthcare systems in Asia. We aimed to provide clinically relevant recommendations for post-operative fragility hip fracture care and rehabilitation to improve patient outcomes and prevent subsequent fractures in Thailand. METHODS: A targeted literature review was conducted to identify key evidence on various elements of post-hip fracture care and rehabilitation. Further discussions at a meeting and over email correspondence led to the development of the recommendations which amalgamate available evidence with the clinical experience of the multidisciplinary expert panel. RESULTS: Our recommendations are categorized by one period domain - acute post-operative period, and five major domains during the post-operative period - rehabilitation, optimization of bone health, prevention of falls, nutritional supplementation, and prophylaxis for venous thromboembolism. A multidisciplinary approach should be central to the rehabilitation process with the involvement of orthopedists, geriatricians/internists, physiatrists, physical and occupational therapists, endocrinologists, pharmacists and nursing staff. Other key components of our recommendations which we believe contribute to better functional outcomes in older patients undergoing hip fracture surgery include comprehensive pre-operative assessments, early surgery, goal setting for recovery and rehabilitation, early mobilization, medication optimization, tailored exercise plans, adequate coverage with analgesia, assessment and appropriate management of osteoporosis with due consideration of the fracture risk, fall prevention plans, and nutritional assessment and support. Patients and their caregivers should be a part of the recovery process at every step, and they should be counseled and educated appropriately, particularly on the importance of adherence to their rehabilitation plan. CONCLUSION: We have provided guidance on the critical domains of clinical care in the post-operative setting to optimize patient outcomes and prevent fracture recurrence. Our recommendations for post-operative care and rehabilitation of older adults with hip fracture can serve as a framework for hospitals across Thailand.

Summary of the Thai Osteoporosis Foundation (TOPF) Clinical Practice Guideline on the diagnosis and management of osteoporosis 2021.

Objectives: The Thai Osteoporosis Foundation (TOPF) is an academic organization that consists of a multidisciplinary group of healthcare professionals managing osteoporosis. The first clinical practice guideline for diagnosing and managing osteoporosis in Thailand was published by the TOPF in 2010, then updated in 2016 and 2021. This paper presents important updates of the guideline for the diagnosis and management of osteoporosis in Thailand. Methods: A panel of experts in the field of osteoporosis was recruited by the TOPF to review and update the TOPF position statement from 2016. Evidence was searched using the MEDLINE database through PubMed. Primary writers submitted their first drafts, which were reviewed, discussed, and integrated into the final document. Recommendations are based on reviews of the clinical evidence and experts' opinions. The recommendations are classified using the Grading of Recommendations, Assessment, Development, and Evaluation classification system. Results: The updated guideline comprises 90 recommendations divided into 12 main topics. This paper summarizes the recommendations focused on 4 main topics: the diagnosis and evaluation of osteoporosis, fracture risk assessment and indications for bone mineral density measurement, fracture risk categorization, management according to fracture risk, and pharmacological management of osteoporosis. Conclusions: This updated clinical practice guideline is a practical tool to assist healthcare professionals in diagnosing, evaluating, and managing osteoporosis in Thailand.

Quality of Life and Depression Status of Caregivers of Patients with Femoral Neck or Intertrochanteric Femoral Fractures during the First Year after Fracture Treatment.

OBJECTIVE: The burden placed on caregivers can negatively affect the functional recovery of patients with hip fractures. It is therefore essential to consider caregivers' well-being during the hip fracture care pathway. The aim of this study is to evaluate caregivers' quality of life and depression status during the first year after hip fracture treatment. METHODS: We prospectively enrolled the primary caregivers of patients with hip fractures admitted to the Faculty of Medicine Siriraj Hospital (Bangkok, Thailand) between April 2019 and January 2020. The quality of life of each caregiver was evaluated using the 36-Item Short Form Survey (SF-36), EuroQol 5-Dimensions 5-Levels (EQ-5D-5L), and EuroQol Visual Analog Scale (EQ-VAS). Their depression statuses were assessed using the Hamilton Rating Scale for Depression (HRSD). The outcome measures were collected during admission as baseline data and 3, 6 months, and 1 year after hip fracture treatment. The repeated measures analysis of variance was used to compare all outcome measures from baseline to each indicated time point. RESULTS: Fifty caregivers were included in the final analysis. The mean SF-36 physical and mental component summary scores decreased significantly from 56.6 to 54.9 (p = 0.012) and 52.7 to 50.4 (p = 0.043), respectively, during the first 3 months after treatment. The physical and mental component summary scores returned to baseline values 12 and 6 months posttreatment, respectively. Although the mean EQ-5D-5L and EQ-VAS scores significantly declined at 3 months, they returned to baseline values within 12 months. As for HRSD, 6%, 56%, 36%, and 6% of the caregivers reported mild depression symptoms at baseline and 3, 6, and 12 months posttreatment, respectively. CONCLUSIONS: The quality of life and depression status of hip fracture patients' caregivers worsen substantially in the first 3 months and return to baseline 1 year after hip fracture treatment. Specific attention and support should be given to caregivers, particularly during this difficult period. Caregivers should be regarded as "hidden patients" who need to be integrated into the hip fracture treatment pathway.

Exploring the osteoporosis treatment gap after fragility hip fracture at a Tertiary University Medical Center in Thailand.

BACKGROUND: (1) To evaluate the prescription rate of anti-osteoporosis medication, and (2) to identify factors associated with patients not receiving anti-osteoporosis medication or, when prescribed, not persisting with medication 1 year after hip fracture treatment. METHODS: We retrospectively reviewed the medical records of all fragility hip fracture patients admitted to the orthopedic unit of the Faculty of Medicine Siriraj Hospital, Mahidol University, between July 1, 2016, and December 31, 2019. We identified patients who did not receive anti-osteoporosis medication both 6 months and 1 year after fracture treatment. Patients who did not receive the medication 1 year after their treatment were enrolled and interviewed using a no-treatment questionnaire. RESULTS: In total, 530 patients with fragility hip fractures were eligible (mean age, 79.0 years), and most (74.5%) were women. Only 148 patients (31.6%) received anti-osteoporosis medication 1 year after hip fracture. Logistic regression analysis identified predictors for not receiving the medication: male sex (OR 1.8; 95% CI 1.1-3.0), Charlson comorbidity index score ≥ 5 (OR 1.5; 95% CI 1.0-2.3), and secondary school education or below (OR 2.0; 95% CI 1.2-3.3). The main reason for not receiving the medication was that healthcare providers neither discussed nor initiated pharmacological treatment for osteoporosis (48.2%). When the medication was prescribed, non-persistence primarily stemmed from transportation difficulties that resulted in patients missing follow-ups (50.0%). CONCLUSIONS: Improved physician attitudes toward anti-osteoporosis medications might enhance the treatment rate. Developing a follow-up team and facilitating access to medications (eg, courier delivery to patients) would promote therapy compliance. TRIAL REGISTRATIONS: The protocol for the first phase and second phase was approved by the Siriraj Institutional Review Board of the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (COA no. Si 180/2021) and for the second phase, patients-informed consent forms used in the cross-sectional component were approved by the Siriraj Institutional Review Board of the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand (COA no. Si 180/2021). The research was registered with the Thai Clinical Trials Registry (TCTR number: 20210824002). The study was conducted in accordance with the Declaration of Helsinki. Each patient (or a relative/caregiver) provided informed consent in writing or by telephone to participate in this second study phase.

Three-year outcomes of a fracture liaison service model at a university-based tertiary care hospital in Thailand.

Fragility hip fracture (FHF) is a serious complication of osteoporosis. A fracture liaison service (FLS) is crucial in preventing FHF. Our retrospective data of 489 patients with FHF and 3-year follow-ups demonstrated that the FLS improved functional outcomes. Our study's mortality rates were lower than in other published series. PURPOSE: This study assessed the 3-year outcomes after fragility hip fracture (FHF) treatment by a multidisciplinary team from the Siriraj Fracture Liaison Service (Si-FLS). The review investigated the administration rates of anti-osteoporosis medication, refracture, and mortality; activities of daily living; mobility; and health-related quality of life. METHODS: A retrospective review was performed of the records of Si-FLS patients given FHF treatment between June 2016 and October 2018. The outcomes were evaluated at 3 time points: before discharge, and 1 and 3 years after treatment. RESULTS: The study enrolled 489 patients (average age, 78). The mortality and refracture rates at 1 year after hip fracture were 13.9% and 1.6%, respectively. At the 3-year follow-up, both rates were higher (20.4% and 5.7%, respectively). The Barthel Index and EuroQoL Visual Analogue Scale had risen to a plateau at the 1-year follow-up and remained stable to the 3-year follow-up. One year after treatment, approximately 60% of the patients could ambulate outdoors, and the proportion remained steady until the 3-year follow-up. There was no difference in the 1- and 3-year follow-up anti-osteoporosis medication administration rates (approximately 40%). CONCLUSIONS: This study confirms the benefits of having a multidisciplinary FLS care team to manage older people with FHF. An FLS improves the care of patients with FHF and the social support of caregivers and relatives. The FLS maintained the functional outcomes of the patients through 3 years of postfracture treatment.

Dual-Frequency Bioelectrical Impedance Analysis is Accurate and Reliable to Determine Lean Muscle Mass in The Elderly.

BACKGROUND: Dual-frequency bioelectrical impedance analysis (DF-BIA) devices are more accessible and affordable than dual-energy X-ray absorptiometry (DXA); however, no studies have reported the accuracy of DF-BIA in body composition measurement, especially in the Thai elderly. The aims of this study were to (1) compare the accuracies of lean muscle masses measured by DF-BIA devices and DXA and (2) assess the reliability of the DF-BIA device. METHODS: This cross-sectional study was conducted on participants older than 60 years who visited the Orthopedic Clinic of Siriraj Hospital. Whole-body and appendicular skeletal muscle masses (ASMs) were measured using DF-BIA (Tanita RD-545), with DXA (GE Lunar iDXA) as the standard reference. The test-retest reliability of the DF-BIA and the agreement between the devices were assessed using the intraclass correlation coefficient (ICC) and Bland-Altman plots. Regression analysis was used to develop an equation to estimate ASM values from BIA close to those from DXA. RESULTS: The mean age of 88 participants was 73.8 (SD 8.0) years, with women predominating (84.1%). The agreement of BIA and DXA was very high for whole-body lean mass (ICC = 0.954) and ASM (ICC = 0.954), but the mean difference in muscle mass from DF-BIA was overestimated. The ICCs of test-retest reliability for whole-body muscle mass and ASM were 0.987 and 0.988, respectively. The equation for corrected ASM was formulated from a linear equation (R2 = 0.93). CONCLUSIONS: Although lean muscle mass from DF-BIA was minimally overestimated relative to DXA, this device had high accuracy and reliability for lean muscle mass evaluation in the elderly. DXA and DF-BIA are interchangeable for the assessment of muscle mass.

Quality improvement initiatives in the care and prevention of fragility fractures in the Asia Pacific region.

This narrative review summarises ongoing challenges and progress in the care and prevention of fragility fractures across the Asia Pacific region since mid-2019. The approaches taken could inform development of national bone health improvement Road Maps to be implemented at scale during the United Nations 'Decade of Healthy Ageing'. PURPOSE: This narrative review summarises recent studies that characterise the burden of fragility fractures, current care gaps and quality improvement initiatives intended to improve the care and prevention of fragility fractures across the Asia Pacific region. METHODS: The review focuses on published studies, reports and quality improvement initiatives undertaken during the period July 2019 to May 2022. RESULTS: Epidemiological studies conducted in countries and regions throughout Asia Pacific highlight the current and projected increasing burden of fragility fractures. Recent studies and reports document a persistent and pervasive post-fracture care gap among people who have sustained fragility fractures. Global initiatives developed by the Fragility Fracture Network and International Osteoporosis Foundation have gained significant momentum in the Asia Pacific region, despite the disruption caused by the COVID-pandemic. The Asia Pacific Fragility Fracture Alliance has developed educational resources including a Hip Fracture Registry Toolbox and a Primary Care Physician Education Toolkit. The Asia Pacific Osteoporosis and Fragility Fractures Society-a new section of the Asia Pacific Orthopaedic Association-is working to engage orthopaedic surgeons across the region in the care and prevention of fragility fractures. The Asia Pacific Consortium on Osteoporosis developed a framework to support national clinical guidelines development groups. Considerable activity at the national level is evident in many countries across the region. CONCLUSION: Development and implementation of national Road Maps informed by the findings of this review are urgently required to respond to the epidemiological emergency posed by fragility fractures during the United Nations 'Decade of Healthy Ageing'.

Surgical treatment for fragility hip fractures during the COVID-19 pandemic resulted in lower short-term postoperative functional outcome and a higher complication rate compared to the pre-pandemic period.

The COVID-19 pandemic adversely affected the functional outcomes of fragility hip fracture patients. This study revealed a higher in-hospital complication rate and lower postoperative function at 3 months among patients treated during the pandemic. Therefore, modified in-hospital and post-discharge protocols should be developed for implementation during pandemic crisis periods. INTRODUCTION: This study aims to investigate the in-hospital complication rate and short-term postoperative functional outcomes of fragility hip fracture (FHF) patients compared between during the COVID-19 pandemic and the same 14-month time period 1 year prior to the pandemic. METHODS: Using data from the Siriraj Fracture Liaison Service registry, FHF patients treated during the COVID-19 pandemic (1 March 2020 to 30 April 2021) were time-matched with FHF patients treated during the pre-pandemic period (1 March 2018 to 30 April 2019). We collected the rate of in-hospital postoperative complications and the postoperative functional outcomes at discharge and 3 months as measured by the Barthel Index (BI) and EuroQol visual analog scale (EQ-VAS). Functional outcome measures were compared between the pre-pandemic and pandemic periods. RESULTS: There were 197 and 287 patients in the pre-pandemic and pandemic groups, respectively. At the 3-month postoperative follow-up, the mean postoperative BI score and change in BI score were both significantly lower in the pandemic group indicating poorer postoperative function. Moreover, FHF patients treated during the pandemic had significantly more in-hospital complications (36.6% vs. 22.8%, p = 0.002). There was no significant difference in the 3-month EQ-VAS or change in the EQ-VAS between groups. CONCLUSION: The results of this study revealed a higher in-hospital complication rate and lower postoperative function at 3 months among FHF patients treated during the COVID-19 pandemic compared to the pre-pandemic period. Therefore, modified in-hospital and post-discharge protocols should be developed for implementation during pandemic crisis periods.

Development and internal validation of a machine-learning-developed model for predicting 1-year mortality after fragility hip fracture.

BACKGROUND: Fragility hip fracture increases morbidity and mortality in older adult patients, especially within the first year. Identification of patients at high risk of death facilitates modification of associated perioperative factors that can reduce mortality. Various machine learning algorithms have been developed and are widely used in healthcare research, particularly for mortality prediction. This study aimed to develop and internally validate 7 machine learning models to predict 1-year mortality after fragility hip fracture. METHODS: This retrospective study included patients with fragility hip fractures from a single center (Siriraj Hospital, Bangkok, Thailand) from July 2016 to October 2018. A total of 492 patients were enrolled. They were randomly categorized into a training group (344 cases, 70%) or a testing group (148 cases, 30%). Various machine learning techniques were used: the Gradient Boosting Classifier (GB), Random Forests Classifier (RF), Artificial Neural Network Classifier (ANN), Logistic Regression Classifier (LR), Naive Bayes Classifier (NB), Support Vector Machine Classifier (SVM), and K-Nearest Neighbors Classifier (KNN). All models were internally validated by evaluating their performance and the area under a receiver operating characteristic curve (AUC). RESULTS: For the testing dataset, the accuracies were GB model = 0.93, RF model = 0.95, ANN model = 0.94, LR model = 0.91, NB model = 0.89, SVM model = 0.90, and KNN model = 0.90. All models achieved high AUCs that ranged between 0.81 and 0.99. The RF model also provided a negative predictive value of 0.96, a positive predictive value of 0.93, a specificity of 0.99, and a sensitivity of 0.68. CONCLUSIONS: Our machine learning approach facilitated the successful development of an accurate model to predict 1-year mortality after fragility hip fracture. Several machine learning algorithms (eg, Gradient Boosting and Random Forest) had the potential to provide high predictive performance based on the clinical parameters of each patient. The web application is available at www.hipprediction.com . External validation in a larger group of patients or in different hospital settings is warranted to evaluate the clinical utility of this tool. TRIAL REGISTRATION: Thai Clinical Trials Registry (22 February 2021; reg. no. TCTR20210222003 ).

No Effect of Oral Mecobalamin on Skin Numbness at 3 Months After Total Knee Arthroplasty: A Randomized, Double-Blinded, Placebo-Controlled Superiority Trial.

Background: An area of skin numbness (AON) around an incision commonly occurs following total knee arthroplasty (TKA). Mecobalamin has been shown to facilitate peripheral nerve recovery in various conditions; accordingly, the present study aimed to investigate the ameliorative effect of mecobalamin on AON following TKA, as compared with a placebo. Methods: This superiority study was a double-blinded, randomized controlled trial. All patients undergoing primary TKA were assessed for eligibility. Included patients were randomized to receive either mecobalamin (500 µg, twice daily) or placebo (corn starch powder; 500 µg, twice daily) for 3 months. The primary outcome was the change in the AON around the surgical site from 2 weeks to 3 months after TKA. Secondary outcomes included the rates of different adverse events, functional outcomes, and visual analogue scale patient satisfaction scores. Results: A total of 154 patients were enrolled, with 77 patients each in the mecobalamin and placebo groups. The mean AON among patients in the mecobalamin group was 61.6 cm2 at baseline (2 weeks) and 29.1 cm2 at 3 months, compared with 55.9 cm2 and 33.2 cm2 among patients in the placebo group, respectively. Intention-to-treat analysis showed no significant difference in the change in AON around the surgical site between the 2 groups (mean difference, 7.5; 95% confidence interval, -4.2 to 25.3; p = 0.159). The rates of adverse events, functional outcomes, and visual analogue scale patient satisfaction score were also not significantly different between groups. Conclusions: Mecobalamin did not demonstrate superiority over a placebo in reducing the AON around the surgical site at 3 months after primary TKA. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of the implementation of multidisciplinary fast-track program for acute geriatric hip fractures at a University Hospital in resource-limited settings.

BACKGROUND: Hip fractures are common among frail, older people and associated with multiple adverse outcomes, including death. Timely and appropriate care by a multidisciplinary team may improve outcomes. Implementing a team to jointly deliver the service in resource-limited settings is challenging, particularly on the effectiveness of patient outcomes. METHODS: A retrospective cohort study to compare outcomes of hip fracture patients aged 65 or older admitted at Siriraj hospital before and after implementation of the Fast-track program for Acute Geriatric Hip Fractures. The primary outcome was the incidence of medical complications. The secondary outcomes were time to surgery, factors related to the occurrence of various complications, in-hospital mortality, and mortality at month 3, month 6 and month 12 after the operation. RESULTS: Three hundred two patients were enrolled from the Siriraj hospital's database from October 2016 to October 2018; 151 patients in each group with a mean age of 80 years were analyzed. Clinical parameters were similar between groups except the Fast-track group comprising more patients with dementia (37.1% VS 23.8%, p < 0.012). In the Fast-track group, there was a significantly higher proportion of patients underwent surgery within 72-h (80.3% VS 44.7%, p < 0.001) and the length of stay was significantly shorter (11 days (8-17) VS 13 days (9-18), p = 0.017). There was no significant difference in medical complications. Stratified analysis by dementia status showed a trend in delirium reduction in both patients with dementia and without dementia groups, and a pressure injury reduction among patients with dementia after the program was implemented but without statistical significance. There was no significant difference in mortality. CONCLUSIONS: The implementation of a multidisciplinary team for hip fracture patients is feasible in resource-limited setting. In the Fast-track program, time to surgery was reduced and the length of stay was shortened. Other outcome benefits were not shown, which may be due to incomplete uptake of all involved disciplines.

Midterm functional recovery of Total knee arthroplasty patients compared between the ATTUNE knee system and the press fit condylar (PFC) SIGMA knee system.

BACKGROUND: The ATTUNE Knee System is a new prosthetic design that has theoretical advantages over the Press Fit Condylar (PFC) Sigma Knee System specific to improved knee kinematics and patellofemoral joint tracking. This study aimed to evaluate functional outcomes compared between the ATTUNE and PFC Sigma designs at a minimum follow-up of 5 years. METHODS: We retrospectively reviewed data from total knee arthroplasty (TKA) patients who received either the ATTUNE or PFC Sigma system during November 2013 to February 2015 at Siriraj Hospital (Bangkok, Thailand). Functional outcomes were evaluated using Timed Up and Go (TUG) test, 2-min walk test (2MWT), modified knee score, numerical rating scale-pain, range of motion (ROM), and rate of anterior knee pain and crepitation at preoperation, 3-months, 1-year, and 5-years postoperatively. RESULTS: Of 113 patients, 59 and 54 received the PFC Sigma and ATTUNE systems, respectively. At a minimum of 5-years follow-up, all functional outcomes improved significantly from the preoperative period although TUG test and 2MWT declined significantly from 1- to 5-years postoperatively only in the PFC Sigma group. The mean ROM at 5-years postoperatively was significantly higher in ATTUNE than in PFC Sigma; however, the difference was small (116° vs. 110°, respectively; p = 0.041). There were no significant differences in any of the other outcome measurements, including anterior knee pain, clunking, and crepitation, between groups at any study time point. CONCLUSIONS: ​Our results revealed no major differences in functional outcomes between the PFC Sigma and ATTUNE TKA designs at an intermediate-term follow-up of at least 5 years. Longer-term follow-up study is needed to evaluate the benefits of the ATTUNE design relative to polyethylene wear and the rate of aseptic loosening.

Stress Fracture of the Femoral Shaft in Paget's Disease of Bone: A Case Report.

Paget's disease of bone (PDB) is a progressive bone disorder characterized by increased osteoclast-mediated bone resorption and abnormal bone formation. Incomplete atypical femoral fracture, appearing radiographically as a stress fracture at the lateral aspect of the femur, is an uncommon low-trauma fracture frequently seen in association with long-term bisphosphonate therapy. We describe the case of a 61-year-old female patient with PDB who developed a stress fracture at the lateral femoral cortex after 5 doses of intravenous bisphosphonate. The conservative treatment plan included discontinuation of bisphosphonate, a continuation of calcium and vitamin D supplementation, and limited weight-bearing for 3 months. The patient's pain level gradually improved after switching to the new treatment plan. At the latest follow-up, approximately 5 years after the initiation of conservative treatment, the patient remained pain-free, and her PDB was well-controlled. However, the fracture line was still visible on the most recent radiograph. Although it remains unclear whether a stress fracture at the lateral femoral cortex occurred due to bisphosphonate therapy or PDB, this case highlights the importance of careful evaluation of any lesion that appears in PDB patients receiving bisphosphonate therapy.

Osteitis Fibrosa Cystica and pathological fractures-the classic but neglected skeletal manifestation of primary hyperparathyroidism: a case report.

BACKGROUND: Osteitis fibrosa cystica is the classic manifestation of primary hyperparathyroidism (PHPT), occurs after prolonged exposure of bone to high serum parathyroid hormone (PTH) level. It has become increasingly rare due to early detection of PHPT. CASE PRESENTATION: A 37-year-old woman was referred to our institution for fixation of multiple fractures of upper and lower extremities that had been reoccurring in the past 5 years. Her medical history showed right-shoulder, left-elbow, and right-femur fractures after a fall 5 years previously. One month ago, she sustained fractures of the right distal humerus, left tibia, and left femur without history of trauma. Upon arrival to our hospital, a thorough review of her plain radiographs demonstrated brown tumors at multiple sites, along with a salt-and-pepper appearance of the skull and a rugger-jersey spine, compatible with osteitis fibrosa cystica. Patient was diagnosed with PHPT, confirmed by high-corrected serum calcium (13.6 [8.6-10.0] mg/dl), low serum phosphate (2.2 [2.5-4.5] mg/dL), high serum alkaline phosphatase (1482 [35-105] U/L), and significantly elevated parathyroid hormone (PTH 3850 [15-65] pg/mL). A histologically confirmed, 2.5-cm parathyroid adenoma was removed by parathyroidectomy. Ten days later, closed reduction and internal fixation of the left proximal femoral shaft was performed. Pain and ambulation were significantly improved 6 months postoperatively. At the 1.5-year follow-up, fracture unions and complete mineralization of brown tumors were noted; the patient could ambulate with neither pain nor an assistive device. CONCLUSIONS: PHPT has become more asymptomatic in countries where routine calcium screening is performed. Nevertheless, the classic skeletal involvement, osteitis fibrosa cystica, should not be overlooked, particularly in young patients who present with a low-energy fracture.