Adjuvant Vitamin D Injection in Elderly Patients Before Intertrochanteric Fracture Surgery: A Randomised Controlled Trial.

Background: There are multiple recommended protocols for Vitamin D (VitD) supplementation in elderly; however, only a few studies achieved to examine the role of VitD supplements before intertrochanteric fracture surgery on mortality and complications after surgery. Methods: This single-center block-randomized double-blinded trial was conducted on 80 patients with intertrochanteric fractures and a sufficient level of 25 (OH) VitD. The intervention group received an intramuscular 300,000 IU VitD ampule before surgery. The primary outcome was a 6-month mortality rate, and the secondary outcomes were 1- and 2-year mortality rates and Harris Hip Score (HHS) in 6, 12, and 24 months after surgery. Chi-square, t-test, repeated measure ANOVA, and Cox regression survival model was used for statistical analysis. Results: 40 patients were allocated to each group. Demographic, clinical characteristics, and preoperative evaluations were not significantly different between the groups. Mortality rate 6-month after the surgery was 7.5% and 10% for the intervention and placebo groups respectively (P value = .71), 15% and 12.5% at 1-year (P value = .83), and 25% and 27.5% at 2-year (P value = .98). Based on the Cox regression model, only age was significantly associated with mortality (HR = 1.229, P value <.001). Significant HHS changes from baseline through 24 months after surgery were observed within both groups; however, mean differences were not significantly different between groups. Conclusions: A single preoperative 300,000 IU VitD did not significantly impact 2-year survival and HHS in patients with intertrochanteric fractures and sufficient serum VitD level.

Comparison of the taste and acceptability of a new high protein ice cream (Nottingham-Ice cream) with standard hospital milkshake oral nutritional supplement in older people with fragility fractures: a short report.

INTRODUCTION: Oral nutritional supplement (ONS) prescription iscommonly recommended for older patients with hip fractures. However, ONS compliance is often low. Ice cream may be a promising nutritional intervention. Using a Plan-Do-Study Act methodology we describe the second cycle of a project using an ice cream based nutritional supplement called Nottingham-Ice cream (N-ICE CREAM) to address malnutrition in older adults. The project aimed to identify whether N-ICE CREAM is a suitable option/alternative to standard ONS. METHODS: Fifty older (≥ 65 years) inpatients with hip or spine fractures were recruited. Both groups received two days each of N-ICE CREAMand milkshake ONS. We measured compliance, acceptability (rating 0"dislike a lot" to 7 "like a lot"), attitudes towards prescription length (rating 0 "very unconfident" to 4 "very confident") and preference. RESULTS: Mean (standard deviation, SD) patient age was 80.6 (7.7) years. The majority (n = 21, 67.7%) preferred N-ICE CREAM. Mean compliance to N-ICE CREAM was greater in both groups (group A (n = 22) 69.9 (30.0)% and group B (n = 26) 56.3 (39.3)%) compared to milkshake ONS (group A (n = 22) 43.4 (4.7)% and group B (n = 26) 53.6 ± (40.2)%). Mean acceptability ratings were higher for N-ICE CREAM, thus the overall impression score was greater. Confidence score for both products decreased with increasing time. CONCLUSIONS: N-ICE CREAM is more accepted by older patients with hip or spine fractures compared to milkshake ONS. Further research should explore long-term compliance and clinical outcomes.

Effects of Teriparatide on Clinical and Radiologic Long-Term Outcomes after Fixation of Pertrochanteric Hip Fractures.

Background: Pertrochanteric hip fractures are common and among serious injuries of the old population with considerable mortality and morbidity. The aim of this study was to evaluate long-term effects of recombinant human parathyroid hormone on postoperative clinical and radiologic outcomes in elderly patients with pertrochanteric hip fractures. Materials and Methods: Between 2016 and 2019, we prospectively assessed 80 patients with pertrochanteric hip fractures who underwent reduction and internal fixation with a dynamic hip screw. Patients were divided randomly into two groups. About 40 patients in the control group who received supplementary calcium (1000 mg/day) and vitamin D (800 UI/day), and 40 others who were treated additionally with 20-28 mg daily teriparatide for three months post-operatively. The functional and radiologic assessment was done using visual analog scale (VAS), Harris hip score (HSS), and standard radiographs of the hip. Results: At the final follow-up, there was a significant difference between the two groups regarding average HSS (68.38 in the control group versus 74.12 in the treatment group, P-value <0.001). VAS score was also significantly lower in the treatment group (P-value <0.001). Regarding radiographic evidence of union, the results were not statistically different between the two groups. Conclusions: The current study illustrated that short-term daily administration of teriparatide improves long-term functional outcome after pertrochanteric hip fracture fixation and can reduce the pain but does not affect union and callus formation.

Local anesthetic with monitored anesthesia care in cephalomedullary nailing of proximal femur fractures.

INTRODUCTION: Proximal femur fractures have high rates of morbidity, mortality, and perioperative complications. Limiting anesthesia, especially in the elderly population, is a priority from a medical perspective. The goal of the current study is to present a technique of using local anesthetic with monitored anesthesia care (MAC) for the fixation of intertrochanteric (IT) femur fractures with cephalomedullary nailing (CMN), provide early clinical results in a small series of patients, and evaluate the safety, efficiency, and anesthetic efficacy of our technique. HYPOTHESIS: The use of only local anesthetic with MAC for the fixation of IT fractures is safe and leads to decreased operative times when compared to spinal and general anesthesia. MATERIALS AND METHODS: Patients undergoing cephalomedullary nailing (CMN) with a long nail for IT femur fractures by a single surgeon from January 2020 to June 2021 were identified retrospectively from a prospectively-collected patient registry. Patient demographics, operative time, length of hospital stay, perioperative medication use, and complications were collected. Analysis of variance, Chi2, linear regression, and two-sampled T-tests were performed to analyze potential differences between the local anesthesia group and the general or spinal anesthesia group. RESULTS: Thirty-seven patients were identified. Eleven patients underwent CMN using local anesthesia with MAC, 11 using spinal anesthesia, and 15 using general anesthesia. The local anesthesia group demonstrated significantly lower operating room times and anesthesia induction to incision time compared to other anesthesia techniques. The local anesthesia group also trended towards less need for vasopressors during surgery and less postoperative delirium. No differences were identified in intraoperative narcotic use, complications, patient mortality, or hospital readmissions. CONCLUSIONS: Local anesthesia with MAC for the treatment of IT fractures with CMN was associated with decreased operating room times and had similar complication rates including blood transfusions, readmissions, and mortalities, when compared to spinal and general anesthesia. LEVEL OF EVIDENCE: III, therapeutic.

Proceso de atención en enfermería basado en mapa de cuidados en persona mayor reintervenida quirúrgicamente por reemplazo de cadera. Reporte de un caso

El proceso de atención en enfermería (PAE) es un método sistemático y organizado que requiere de un entrenamiento específico, tener conocimientos y habilidades prácticas que proporcionan las herramientas para brindar cuidado abordando las dimensiones de forma holística a partir de una interacción directa con el paciente, la familia y el entorno social. Se presenta el PAE de una persona mayor, femenina, de 65 años de edad, con pluripatologías: síndrome purpúrico, monoparesia de miembro inferior derecho y síndrome convulsivo, reintervenida quirúrgicamente de un reemplazo de cadera derecha. Se plantea el PAE y sus cinco etapas: valoración, diagnóstico, planeación, ejecución y evaluación; siguiendo la valoración por dominios. El plan de cuidados se realiza con el enfoque de mapa de cuidados en la situación quirúrgica, diagnóstico NANDA International, lnc. La evaluación de intervenciones NIC (Nursing Interventions Classification) y resultados NOC (Nursing Outcomes Classification).

The Nursing Care Process (NCP) is a systematic and organized method that requires specific training, knowledge and practical skills that provide the tools needed to provide care by addressing the dimensions holistically from direct interaction with the patient, the family and social environment. Te NCP of a 65-year-old female elderly person with multiple pathologies; purpuric syndrome, right lower limb monoparesis and convulsive syndrome, who underwent surgery for a right hip replacement is presented. The Nursing Care Process (NCP) and its five stages are proposed: assessment, diagnosis, Outcomes/ Planning, Implementation and evaluation; following the valuation by domains. The care plan was carried out with the care map approach, NANDA Internacional Inc. Te evaluation of NIC (Nursing Interventions Classification) interventions and NOC (Nursing Outcomes Classification) results.

Nutrition and Exercise Treatment of Sarcopenia in Hip Fracture Patients: Systematic Review.

BACKGROUND: This study aimed to investigate nutritional or rehabilitation intervention protocols for hip fracture patients with sarcopenia and to analyze the effect of these protocols through a systematic review of studies that reported clinical results. METHODS: Studies were selected based on the following criteria: (1) study design: randomized controlled trials or non-randomized comparative studies; (2) study population: patients with hip fracture; (3) intervention: nutritional or rehabilitation; and (4) reporting the clinical outcomes and definition of sarcopenia. RESULTS: Of the 247 references initially identified from the selected databases, 5 randomized controlled studies and 2 comparative studies were selected for further investigation. The total number of patients was 497. We found 2 specific rehabilitation interventions, one medication intervention using erythropoietin, and 4 nutritional interventions using amino-acid or protein. Among the studies included in this systematic review, 2 studies did not find a clear statistical difference in assessment tools compared to controls after intervention. On the other hand, the rest of the studies positively interpreted the results for intervention. The most frequently used assessment tool for intervention was handgrip strength. CONCLUSIONS: Although mainstream methods of intervention for sarcopenia include nutritional, exercise, and drug interventions, the validity of these interventions in elderly hip fractures has not been clearly proven. In addition, as most studies only reported short-term results, there is no consensus on the optimal long-term treatment.

Acute exacerbation of COPD increases the risk of hip fractures: a nested case-control study from the Korea National Health Insurance Service.

BACKGROUND/AIMS: Hip fracture and acute exacerbation of chronic obstructive pulmonary disease (AE-COPD) could increase mortality in patients with COPD. There are no data on the relationship between AE-COPD and hip fracture, which may significantly affect the prognosis of patients with COPD. Therefore, we conducted this study to determine the effects of AE-COPD on hip fractures in patients with COPD. METHODS: This retrospective, nested, case-control study included 253,471 patients with COPD (≥ 40 years of age) identified from the Korea National Health Insurance Service-National Health Screening Cohort (NHIS-HEALS) from 2002 to 2015. Among 176,598 patients with COPD, 1,415 patients with hip fractures were identified. Each case was matched to one control for age (within 10 years), sex, and year of COPD diagnosis. We estimated the adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for hip fractures associated with AE-COPD using conditional logistic regression analysis, adjusting for underlying diseases and smoking history. RESULTS: In patients with AE-COPD, the risk of hip fracture was 2.50 times higher, regardless of systemic corticosteroid use and underlying disease (aOR, 2.50; 95% CI, 1.67 to 3.75). The risk of hip fracture increased if there was one episode of AE in the year before hip fractures (aOR, 2.25; 95% CI, 1.66 to 3.05). Moreover, the risk of hip fracture also increased in patients with more than two episodes of AE the year before hip fractures (aOR, 2.57; 95% CI, 1.61 to 4.10). CONCLUSION: AE-COPD increases the risk of hip fracture regardless of underlying diseases, including osteoporosis, and treatment with systemic corticosteroids.

A systematic review of using electrical stimulation to improve clinical outcomes after hip fractures.

BACKGROUND: Pain and muscles weakness often delays regaining independent mobility following hip fracture surgery. Electrical stimulation may relieve pain and improve muscle strength and function. PURPOSE: To systematically review and evaluate available literature examining the effectiveness of using electrical stimulation to promote clinical outcomes after hip fractures. METHODS: Two researchers independently searched MEDLINE, CINAHL, EMBASE, Web of Science, Cochrane Reviews, Physiotherapy Evidence Database, and PsycInfo from inception to July 1, 2018, with no restrictions. The quality and fidelity of the included interventions were assessed, and expert consultation was conducted to help explain the results. RESULTS: We identified 432 records through database searching. Initial screening indicated 24 articles were appropriate for full-text review, and four articles met the inclusion criteria. In included studies, electrical stimulation (i.e. TENS) reduced pain (mean difference (MD) = 3.3 points on 10-point Visual Analogue Scale, p < .001), improved range of motion (ROM) (MD: 25.7°, p < .001), and accelerated functional recovery immediately after hip fracture (p < .001). Conflicting evidence existed when using neuromuscular electrical stimulation to improve muscle strength and other functional outcomes (e.g. mobility); however, nine experts advised that longer-term interventions might be necessary to achieve significant improvment in muscle strength. CONCLUSION: Available evidence, albeit limited, supports the early application of noninvasive electrical stimulation (e.g. TENS) for improving clinical outcomes (i.e. reducing pain, improving ROM, and accelerating functional recovery after hip fractures). We could not find conclusive evidence on the effectiveness of using electrical stimulation to improve muscle strength. This review establishes the need for future additional high-quality trials in this field.

Postoperative delirium in geriatric patients with hip fractures.

Postoperative delirium (POD) is a frequent complication in geriatric patients with hip fractures, which is linked to poorer functional recovery, longer hospital stays, and higher short-and long-term mortality. Patients with increased age, preoperative cognitive impairment, comorbidities, perioperative polypharmacy, and delayed surgery are more prone to develop POD after hip fracture surgery. In this narrative review, we outlined the latest findings on postoperative delirium in geriatric patients with hip fractures, focusing on its pathophysiology, diagnosis, prevention, and treatment. Perioperative risk prediction, avoidance of certain medications, and orthogeriatric comprehensive care are all examples of effective interventions. Choices of anesthesia technique may not be associated with a significant difference in the incidence of postoperative delirium in geriatric patients with hip fractures. There are few pharmaceutical measures available for POD treatment. Dexmedetomidine and multimodal analgesia may be effective for managing postoperative delirium, and adverse complications should be considered when using antipsychotics. In conclusion, perioperative risk intervention based on orthogeriatric comprehensive care is the most effective strategy for preventing postoperative delirium in geriatric patients with hip fractures.

The effect of zoledronic acid and high-dose vitamin D on function after hip fractures. A prospective cohort study.

PURPOSE: Hip fractures are associated with functional decline and increased mortality. The aim of this study was to investigate the effect of zoledronic acid and high-dose vitamin D on function and mortality after hip fractures. PATIENTS AND METHODS: Forty-five patients received zoledronic acid and high dose of vitamin D during hospitalization after fracture management. These patients were compared with a control group of 46 patients. Pre- and postoperative prospectively collected data including ASA score, Charlson comorbidity score, presence of dementia, Vitamin D, and the Barthel index were available. Final follow-up was performed after one year. Primary outcome was patients' function at final follow-up as measured with Barthel index score. Secondary outcomes included mortality, assessment of pain, and complications. RESULTS: Barthel index score at final follow-up was decreased in both groups. There was no significant difference in Barthel index between the two groups (15.5 ± 5.0 vs 15.8 ± 5.8, p = 0.850). However, the Barthel index in the control group decreased beyond the smallest detectable change (3 points). Mortality was statistically different between groups (8.8% vs 28.2%, p = 0.047). Complications and pain at final follow-up were not different between groups. Multivariate analysis revealed that preoperative Barthel index and Charlson comorbidity score independently affected function at final follow-up. Logistic regression analysis disclosed that not receiving active treatment and complications were associated with increased mortality. CONCLUSIONS: Medical treatment after surgical management of hip fractures results in reduced mortality and lessens the functional decline associated with these fractures.

Influence of Hypovitaminosis D on the Ocurrence of Fractures.

Objective To measure the levels of vitamin D in patients hospitalized for fractures and to evaluate its relationship with fractures. Methods A primary, analytical, cross-sectional, non-interventional, observational, controlled study was conducted in humans. The serum measurement of: vitamin D, parathyroid hormone (PTH), calcium, phosphorus, magnesium and albumin was performed in 49 patients who were consecutively hospitalized for surgery due to fracture(s) (study group), and in 50 patients without fractures, from the various outpatient clinics, and who underwent routine tests (control group). Results The mean level of 25-hydroxyvitamin D (25[OH]D) in patients with fractures was of 23.78 ± 8.01 ng/mL (61.22% of patients with fractures had hypovitaminosis D). The mean 25(OH)D of the control group was of 37.52 ± 9.21 ng/mL (10% of the patients had hypovitaminosis D). Most cases of hypovitaminosis (96%) did not course with secondary hyperparathyroidism (mean PTH = 41.80 ± 22.75 pg/mL). Conclusion Hypovitaminosis D was found in a significant percentage (61.22%) of the patients who suffered fractures. Further studies on the subject are needed to better understand the influence of hypovitaminosis D on the occurrence of fractures, as well as the benefits of vitamin D supplementation in these patients.

Preoperative Vitamin D Deficiency is Associated with Postoperative Functional Recovery and Complications after Hip Fracture Surgery.

BACKGROUND: Low concentrations of vitamin D are considered one of the risk factors for hip fracture and are associated with worse outcomes. The purpose of this retrospective study was to compare vitamin D deficient group and vitamin D sufficient group and assess the association preoperative vitamin D deficiency and postoperative walking ability after hip fracture surgery. METHODS: Between January 2014 and January 2020, 1,029 elderly patients with hip fracture (243 in men and 785 in women) were measured preoperative serum 25-hydroxy-vitamin D3 levels. Among 1,029 elderly patients, 702 patients were classified as Vitamin D deficient group (<20 ng/mL). Outcome parameters for functional recovery were the length of the hospital stay and KOVAL score, and those for complications were delirium, pneumonia, and thromboembolism. RESULTS: The mean length of the hospital stay in the vitamin D deficient group was significantly longer than in the vitamin D sufficient group (27.7±17.8 vs. 2.9±11.8 days; odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.05; P=0.001). The mean postoperative KOVAL score in the deficient group was significantly higher than in the sufficient group (4.0±2.1 vs. 3.1±1.9 days; OR, 1.21; 95% CI, 1.11-1.32; P=0.001). Vitamin D deficiency was significantly associated with a higher risk of delirium and pneumonia in deficiency group. CONCLUSIONS: Preoperative vitamin D deficiency in hip fractures patients was associated with prolonged duration of hospital stay and decrease of postoperative ambulatory status, and may increase the risk of delirium and pneumonia. Therefore, it is necessary to evaluate the preoperative vitamin D level and recommend vitamin D supplementation in elderly patients with a high probability of hip fracture.

"Context, content, and system" supporting digital health hub (DHH)-enabled models of care (MoCs) for fragility hip fractures: perspectives of diverse multidisciplinary stakeholders in South Australia from qualitative in-depth interviews.

Combining thematic analysis and a human-computer persuasive systems framework suggests that hip fracture recovery among older people can be enhanced through person-centered digital health hub models of care focused on behavior change education and integrated care. The findings intend to guide settings involving comorbid conditions and low- and middle-income countries in developing innovative digital health solutions. PURPOSE: The purpose of this study was to understand stakeholders' perspectives on the development of a digital health-enabled model of care for fragility hip fractures and to map out factors that could influence the design and implementation of such a model. METHODS: Qualitative in-depth interviews were conducted with stakeholders from various clinical disciplines, allied health, and computer science. A hybrid process involving thematic analysis of the raw data using inductive coding was the first step. In the second step, the tenets of a theoretical framework (health behavior change supporting systems) were deductively applied to the thematic constructs generated as part of the first step of the analysis. RESULTS: In total, 24 in-depth interviews were conducted with stakeholders. We identified 18 thematic constructs presented under the categories of context, content, and system. Context covered patient characteristics such as frailty, digital literacy, and patient or carer participation, whereas healthcare delivery aspects included the structure and culture of existing practice and the need for innovative holistic models of care. Content outlines the active ingredients and approach in developing a digital health hub, and it highlights the importance of targeted education and behavior change. The system is a complicated matrix crossing different aspects of healthcare and offering a value proposition design through personalization across modes of content delivery. This must foster trust, ensure adequate financing, and support ownership and privacy by establishing appropriate mechanisms for embedding change. CONCLUSION: The findings from this study provide insights around potential factors related to patients, community support, and healthcare delivery influencing the design and next-stage implementation of a digital health hub model of care for fragility hip fractures.

Influence of Hypovitaminosis D on the Ocurrence of Fractures / Influência da hipovitaminose D na ocorrência das fraturas

Abstract Objective To measure the levels of vitamin D in patients hospitalized for fractures and to evaluate its relationship with fractures. Methods A primary, analytical, cross-sectional, non-interventional, observational, controlled study was conducted in humans. The serum measurement of: vitamin D, parathyroid hormone (PTH), calcium, phosphorus, magnesium and albumin was performed in 49 patients who were consecutively hospitalized for surgery due to fracture(s) (study group), and in 50 patients without fractures, from the various outpatient clinics, and who underwent routine tests (control group). Results The mean level of 25-hydroxyvitaminD (25[OH]D) in patients with fractures was of 23.78 ± 8.01 ng/mL (61.22% of patients with fractures had hypovitaminosis D). The mean 25(OH)D of the control group was of 37.52 ± 9.21 ng/mL (10% of the patients had hypovitaminosis D). Most cases of hypovitaminosis (96%) did not course with secondary hyperparathyroidism (mean PTH = 41.80 ± 22.75 pg/mL). Conclusion Hypovitaminosis D was found in a significant percentage (61.22%) of the patients who suffered fractures. Further studies on the subject are needed to better understand the influence of hypovitaminosis D on the occurrence of fractures, as well as the benefits of vitamin D supplementation in these patients.

Resumo Objetivo Dosar a vitamina D nos pacientes internados por fratura e avaliar sua relação com as fraturas. Métodos Realizou-se estudo primário, analítico, transversal, não intervencional, observacional, controlado, em seres humanos. Fez-se a dosagem sérica de: vitamina D, paratormônio(PTH), cálcio, fósforo, magnésio e albumina em 49 pacientes que foram internados consecutivamente para cirurgia devido a fratura(s) (grupo de estudo), e em 50 pacientes, dos diversos ambulatórios, sem fraturas, e que realizaram exames de rotina (grupo de controle). Resultados A média de 25-hidroxivitamina D (25[OH]D) nos pacientes com fraturas foi de 23,78 ± 8,01 ng/mL (61,22% dos pacientes com fraturas apresentaram hipovitaminose D). A média de 25(OH)D do grupo de controle foi de 37,52 ± 9,21 ng/mL (10% dos pacientes apresentaram hipovitaminose D). A maioria dos casos de hipovitaminose (96%) não cursou com hiperparatireoidismo secundário (média do PTH = 41,80 ± 22,75 pg/mL). Conclusão A hipovitaminose D foi encontrada em um percentual expressivo (61,22%) dos pacientes que sofreram fraturas. Mais estudos sobre o assunto são necessários para se compreender melhor a influência da hipovitaminose D na ocorrência das fraturas e os benefícios da suplementação com vitamina D nesses pacientes.

Hip Fractures in Malta: Are we Missing an Opportunity?

Introduction Osteoporosis is a bone disease that is both preventable and treatable. It usually becomes evident when a fragility fracture occurs. Unfortunately, most studies show that only a small percentage of individuals at increased risk of fracture are assessed and treated, even following a fragility fracture. Objective The aim of this study was to determine whether patients suffering from a low-energy hip fractures in the Maltese Islands are given osteoporosis treatment. Method All patients older than 50 years presenting to the acute care hospitals in Malta and Gozo with a fragility hip fracture during December 1, 2015 and November 30, 2016 were included. Data on mortality, other fragility fractures, prescription of calcium, vitamin D, and antiresorptive therapy were collected. Results Calcium with vitamin D supplements were prescribed to 40% of patients; however, only 2.64% of patients were given pharmacological therapy. Following a hip fracture, the mortality rate was 18.5% at 1 year and 26.21% at 2 years. Apart from a high mortality rate, 28.19% of individuals sustained another fragility fracture before or after the hip fracture. Conclusion There should be increased osteoporosis awareness in Malta and a national bone mineral density screening program should be set up. An active role of the orthogeriatrics team in the management and treatment of osteoporosis following a fragility fracture might improve treatment rate and decrease refracture and mortality rates.

Application of the Trabecular Bone Score in Clinical Practice.

The trabecular bone score (TBS) was introduced as an indirect index of trabecular microarchitecture, complementary to bone mineral density (BMD), and is derived using the same dual energy X-ray absorptiometry images. Recently, it has been approved for clinical use in Korea. Therefore, we conducted a comprehensive review to optimize the use of TBS in clinical practice. The TBS is an independent predictor of osteoporotic fractures in postmenopausal women and men aged >50 years. The TBS is potentially useful in monitoring the skeletal effects of anabolic agents but not of antiresorptive agents. In postmenopausal women with type 2 diabetes mellitus, the TBS assesses osteoporotic fracture risk not captured by BMD. However, high body mass index and soft tissue thickness can cause underestimation of the TBS; however, this limitation has been improved in recent versions of the TBS software. However, a high precision error and low reproducibility limit the use of TBS. This review may provide information on the application of the TBS in clinical practice based on reliable evidence.

Hospitalisations for falls and hip fractures attributable to vitamin D deficiency in older Australians.

Vitamin D deficiency is associated with an increased risk of falls and fractures. Assuming this association is causal, we aimed to identify the number and proportion of hospitalisations for falls and hip fractures attributable to vitamin D deficiency (25 hydroxy D (25(OH)D) <50 nmol/l) in Australians aged ≥65 years. We used 25(OH)D data from the 2011/12 Australian Health Survey and relative risks from published meta-analyses to calculate population-attributable fractions for falls and hip fracture. We applied these to data published by the Australian Institute of Health and Welfare to calculate the number of events each year attributable to vitamin D deficiency. In men and women combined, 8·3 % of hospitalisations for falls (7991 events) and almost 8 % of hospitalisations for hip fractures (1315 events) were attributable to vitamin D deficiency. These findings suggest that, even in a sunny country such as Australia, vitamin D deficiency contributes to a considerable number of hospitalisations as a consequence of falls and for treatment of hip fracture in older Australians; in countries where the prevalence of vitamin D deficiency is higher, the impact will be even greater. It is important to mitigate vitamin D deficiency, but whether this should occur through supplementation or increased sun exposure needs consideration of the benefits, harms, practicalities and costs of both approaches.

Posterolateral or direct lateral approach for hemiarthroplasty after femoral neck fractures: a systematic review.

BACKGROUND: The posterolateral approach (PLA) and direct lateral approach (DLA) are the most commonly used approaches for inserting a hemiarthroplasty in the treatment of femoral neck fractures. A recent review concluded that the routine use of PLA should be questioned, but this conclusion itself can be questioned. The aim of this study is to provide an updated overview and critical appraisal of the available evidence, focussing on outcomes most relevant for patients. METHODS: We conducted a comprehensive search of literature in the MEDLINE and EMBASE databases and Cochrane Library. Studies (till June 2018) to identify hip fracture clinical trials/comparative studies comparing alternative surgical approaches (PLA and DLA). We explored sources of heterogeneity and conducted pooled analyses when appropriate. RESULTS: 264 potentially eligible studies were identified of which 1 RCT, 3 prospective, 3 registry data and 5 retrospective studies were included. The RCT consisted performance and attrition bias. The mean MINORS score of the prospective/register studies was 17.3 (SD 3.5) and 13.8 (SD 1.9) of the 5 retrospective studies. The GRADE score for all the outcomes was very low. Due to the high and various types of biases across the included studies, we did not pool the data. None of studies assessed the activities of daily living functionality. 6 studies reported significantly more dislocations or reoperations due to dislocation in the PLA group, 6 other studies found no differences. DLA patients were more likely to develop abductor insufficiency leading to limping and more need for walking aids. The PLA patients tended to have better quality of life, less pain and more satisfaction compared to the DLA patients. CONCLUSION: Based on low-quality studies, PLA may be associated with more dislocations, but patients had less walking problems and a lower tendency to abductor insufficiency compared with DLA. Further clinical trials with methodology rigor are needed to determine which approach is more effective in terms of outcomes relevant to patients.

The efficacy of teriparatide on lumbar spine bone mineral density, vertebral fracture incidence and pain in post-menopausal osteoporotic patients: A systematic review and meta-analysis.

OBJECTIVE: Teriparatide has been increasingly utilized in the management of osteoporosis. The efficacy of low and high dose teriparatide on lumbar spine bone mineral density, vertebral fracture incidence and pain is unknown. We sought to determine the efficacy of teriparatide on these patient-important outcomes using a systematic review and meta-analysis. METHODS: A systematic search of electronic databases (MEDLINE, EMBASE, CENTRAL, CINAHL) was performed to identify randomized controlled trials (RCTs) that evaluate teriparatide to any comparator for the treatment of osteoporosis in postmenopausal women. The Grades of Recommendation Assessment, Development and Evaluation (GRADE) criteria were used by two independent reviewers to assess the strength and quality of evidence. RESULTS: A total of 20 studies (n = 6024) were included in this review, with 2855 patients receiving teriparatide and 3169 patients receiving placebo or control treatment. A teriparatide dose of 20 µg/day increased lumbar spine bone mineral density (BMD) (standardized mean difference (SMD) 0.34 standard deviation (SD) units higher (95% CI 0.19-0.48 SDs higher) in comparison to placebo. Relative to anti-resorptive agents, 20 µg/day of teriparatide had a range from 0.14 SD units to 0.96 SD units higher (95% CI, 0.08 SDs lower to 0.36 SDs higher, CI, 0.33-1.59 SDs higher, respectively). 20 µg/day teriparatide had a significant effect on pain severity to placebo or control (SMD 0.80, 95% CI, 1.16-0.43 SDs lower) and also decreased the incidence of vertebral fractures compared to placebo (relative risk 0.31, 95% CI 0.21 to 0.46). Arthralgia and extremity pain incidence were also calculated; there were 15 and 8 fewer events per 1000 patients with the use of 20 µg/day of teriparatide compared to placebo or control, respectively. CONCLUSION: High quality evidence supports the utilization of teriparatide 20 µg/day dose to significantly improve lumbar spine BMD and decrease incidence of vertebral fractures and pain severity relative to all comparators. 40 µg/day dose of teriparatide demonstrated significantly better results with prolonged treatment. This data is valuable for clinicians involved in the care of this growing demographic of patients. Further investigation on the safety and efficacy of teriparatide in higher doses for the long-term treatment of osteoporosis in postmenopausal women should be conducted through high-quality clinical trials.

[Proximal femoral nail anti rotation under local anesthesia for femoral intertrochanteric fractures in high-risk patients].

OBJECTIVE: To compare the clinical efficacy under local anesthesia and general anesthesia proximal femoral nail anti-rotation(PFNA) fixation for intertrochanteric fracture of femur in high risk patients. METHODS: From February 2018 to February 2019, 32 patients underwent PFNA operation due to intertrochanteric fracture of femur, including 16 patients undergoing PFNA operation under local anesthesia, 9 males and 7 females, aged 54 to 98 (82.43±9.30) years and hospitalized for (10.94±5.30) days;16 patients undergoing PFNA operation under general anesthesia, 6 males and 10 females, aged 51 to 83 (72.69±9.48) years and hospitalized for (12.88±4.12) days. The patients' gender, age, fracture AO classification, preoperative VAS (visual analogue score), preoperative ASA condition grade, postoperative 1st day resting state VAS, hospitalization cost and length of stay were recorded. RESULTS: All patients recovered well, the wound healed well, and the ability of lower limb activity was restored. The average follow-up time was 4.6 months. There was significant difference in age between two groups (P< 0.05);there was no significant difference in sex ratio, AO classification of fracture and VAS before operation (P>0.05). There was no significant difference on ASA between two groups (P>0.05), but there was significant difference on ASA≥grade Ⅲ between two groups (P<0.05). In local anesthesia group, VAS pain score was 4.19±1.50, which was tolerable. There was no significant difference in postoperative 1st day resting state VAS, average hospitalization cost and average length of stay between two groups(P>0.05). CONCLUSION: Under the multi-disciplinary diagnosisand treatment mode, the method of PFNA operation is safe and feasible, the patients with local anesthesia are older, and the proportion of patients with ASA≥grade Ⅲ is higher, which is better for some elderly high-risk patients than general anesthesia.