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.

Improving fragility hip fracture care through data: a multicentre experience from a country with an emerging economy during the COVID-19 pandemic.

INTRODUCTION: In low-to-middle-income countries (LMIC), the orthogeriatric model of care is still in its early stages of development. This study describes the initial results of the first online fragility hip fracture database to be setup in the Philippines using a modified minimum common dataset to generate outcomes data based on current hospital practices. METHODS: A multicentre prospective cohort study among 12 Philippine hospitals was conducted from June 2020 to February 2021. Thirty-day mortality, morbidity and mobility were measured. Significant factors associated with mortality were determined. RESULTS: 158 elderly patients with fragility hip fractures were included in the study. Nine patients (5.7%) were confirmed or suspected to have COVID-19 infection. Median time of injury to admission was at least 3 days (IQR: 1.0-13.7). Overall, 80% of patients underwent surgical intervention with a median time from admission to surgery of at least 5 days (IQR: 2.5-13.6). Thirty-day mortality and morbidity rates for acute fragility fractures were 3.7%. Factors significantly associated with early mortality were poor prefracture mobility, COVID-19 infection, radiograph of the abnormal chest and conservative treatment. Non-surgical patients had no functional mobility or were wheelchair users and had a significantly higher morbidity rate than surgically treated patients (13.6% vs 1.8%; p=0.031). CONCLUSION: Despite treatment delays unique to an LMIC, short-term outcomes remain favourable for non-COVID-19 fragility hip fracture patients treated with surgery. Prompt admission and multidisciplinary care for elderly hip fracture patients while maintaining protective measures for COVID-19 infection control are recommended. The quality of data collected illustrates how this online database can provide a framework for a sustainable audit or registry as well as provide a platform for the introduction of orthogeriatric concepts at a multiregional scale.

Service availability and readiness for hip fracture care in low- and middle-income countries in South and Southeast Asia.

Aims: The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries (LMIC) in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines). Methods: The World Health Organization Service Availability and Readiness Assessment tool was used to collect data on the care of hip fractures in Malaysia, Thailand, the Philippines, Sri Lanka, and Nepal. Respondents were asked to provide details about the current pathway of care for patients with hip fracture, including pre-hospital transport, time to admission, time to surgery, and time to weightbearing, along with healthcare professionals involved at different stages of care, information on discharge, and patient follow-up. Results: Responses were received from 98 representative hospitals across the five countries. Most hospitals were publicly funded. There was consistency in clinical pathways of care within country, but considerable variation between countries. Patients mostly travel to hospital via ambulance (both publicly- and privately-funded) or private transport, with only half arriving at hospital within 12 hours of their injury. Access to surgery was variable and time to surgery ranged between one day and more than five days. The majority of hospitals mobilized patients on the first or second day after surgery, but there was notable variation in postoperative weightbearing protocols. Senior medical input was variable and specialist orthogeriatric expertise was unavailable in most hospitals. Conclusion: This study provides the first step in mapping care pathways for patients with hip fracture in LMIC in South Asia. The previous lack of data in these countries hampers efforts to identify quality standards (key performance indicators) that are relevant to each different healthcare system.

The global burden of fragility fractures - what are the differences, and where are the gaps.

The current burden of fragility fractures is enormous, and it is set to increase rapidly in the coming decades as humankind enters a new demographic era. The purpose of this review is to consider, in different settings: • The human and economic toll of fragility fractures. • Risk factors for fragility fractures. • Current acute management of fragility fractures. • Current care gaps in both secondary and primary fracture prevention. A summary of global, regional, and national initiatives to improve the quality of care is provided, in addition to proposals for the research agenda. Systematic approaches to improve the acute care, rehabilitation and prevention of fragility fractures need to be developed and implemented rapidly and at scale in high-, middle- and low-income countries throughout the world. This must be an essential component of our response to the ageing of the global population during the remainder of the current United Nations - World Health Organization "Decade of Healthy Ageing".

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'.

Experience of a systematic approach to care and prevention of fragility fractures in New Zealand.

This narrative review describes efforts to improve the care and prevention of fragility fractures in New Zealand from 2012 to 2022. This includes development of clinical standards and registries to benchmark provision of care, and public awareness campaigns to promote a life-course approach to bone health. PURPOSE: This review describes the development and implementation of a systematic approach to care and prevention for New Zealanders with fragility fractures, and those at high risk of first fracture. Progression of existing initiatives and introduction of new initiatives are proposed for the period 2022 to 2030. METHODS: In 2012, Osteoporosis New Zealand developed and published a strategy with objectives relating to people who sustain hip and other fragility fractures, those at high risk of first fragility fracture or falls and all older people. The strategy also advocated formation of a national fragility fracture alliance to expedite change. RESULTS: In 2017, a previously informal national alliance was formalised under the Live Stronger for Longer programme, which includes stakeholder organisations from relevant sectors, including government, healthcare professionals, charities and the health system. Outputs of this alliance include development of Australian and New Zealand clinical guidelines, clinical standards and quality indicators and a bi-national registry that underpins efforts to improve hip fracture care. All 22 hospitals in New Zealand that operate on hip fracture patients currently submit data to the registry. An analogous approach is ongoing to improve secondary fracture prevention for people who sustain fragility fractures at other sites through nationwide access to Fracture Liaison Services. CONCLUSION: Widespread participation in national registries is enabling benchmarking against clinical standards as a means to improve the care of hip and other fragility fractures in New Zealand. An ongoing quality improvement programme is focused on eliminating unwarranted variation in delivery of secondary fracture prevention.

Exploring barriers to, and enablers of, evidence-informed hip fracture care in five low- middle-income countries: China, India, Thailand, the Philippines and Vietnam.

Globally, populations are ageing and the estimated number of hip fractures will increase from 1.7 million in 1990 to more than 6 million in 2050. The greatest increase in hip fractures is predicted in Low- and Middle-Income Countries (LMICs), largely in the Asia-Pacific region where direct costs are expected to exceed $US15 billion by 2050. The aims of this qualitative study are to identify barriers to, and enablers of, evidence-informed hip fracture care in LMICs, and to determine if the Blue Book standards, developed by the British Orthopaedic Association and British Geriatrics Society to facilitate evidence-informed care of patients with fragility fractures, are applicable to these settings. This study utilized semi-structured interviews with clinical and administrative hospital staff to explore current hip fracture care in LMICs. Transcribed interviews were imported into NVivo 12 and analysed thematically. Interviews were conducted with 35 participants from 11 hospitals in 5 countries. We identified five themes-costs of care and the capacity of patients to pay, timely hospital presentation, competing demands on limited resources, delegation and defined responsibility and utilization of available data-and within each theme, barriers and enablers were distinguished. We found a mismatch between patient needs and provision of recommended hip fracture care, which in LMICs must commence at the time of injury. This study describes clinician and administrator perspectives of the barriers to, and enablers of, high-quality hip fracture care in LMICs; results indicate that initiatives to overcome barriers (in particular, delays to definitive treatment) are required. While the Blue Book offers a starting point for clinicians and administrators looking to provide high-quality hip fracture care to older people in LMICs, locally developed interventions are likely to provide the most successful solutions to improving hip fracture care.

Economic burden and the effects of early versus delayed hospitalization on the treatment cost of patients with acute fragility hip fractures under the UPM-PGH Orthogeriatric Multidisciplinary Fracture Management Model and Fracture Liaison Service.

OBJECTIVES: Fragility hip fractures present not only as a significant cause of morbidity and mortality to the elderly population but also as an important source of financial burden due to staggering costs for treatment. This study is designed to determine the effects of timing of hospitalization to the treatment costs of patients with acute fragility hip fractures. METHODS: In this retrospective cohort study, the patient database of the University of the Philippines Manila-Philippine General Hospital Orthogeriatric Multidisciplinary Fracture Management Model and Fracture Liaison Service was reviewed to investigate the effects of timing of hospitalization to the treatment cost of patients with acute fragility hip fractures admitted in a tertiary government hospital. The economic burden of this group of patients was also computed. RESULTS: A total of 118 patients were enrolled in the study with 54 patients in the early hospitalization (EH) group (≤ 3 days from injury) and 64 in the delayed hospitalization (DH) group (4-28 days). Median treatment cost is less among the EH group than those who were in the DH group (P = 0.0362). The computed economic burden of patients with acute fragility hip fractures is PhP 1,094,048,363.00 (USD 22,595,007.79) per year in the Philippines. CONCLUSIONS: Fragility hip fractures impose significant financial impact; and therefore, recommend early hospitalization to lessen treatment cost. Future studies should also be undertaken to investigate other interventions that may help alleviate this burden.

3-in-1: bilateral subcutaneous leg abscesses and liver abscess from Klebsiella pneumoniae.

Hypervirulent strains of Klebsiella pneumoniae are known to cause liver abscesses and other metastatic infections. Being Asian and having diabetes are known host risk factors. Here we present an unusual case of a Filipino ballet dancer-choreographer with diabetes presenting with bilateral leg pains initially thought to be cellulitis, but was eventually diagnosed as bilateral subcutaneous leg abscesses. He also had a liver abscess, thankfully asymptomatic, which was only discovered on imaging. The occurrence of three distant abscesses in one patient, hence '3-in-1,' makes this case worth reporting. Bilateral subcutaneous leg abscesses as the presenting manifestation of this infection have not been reported yet. We hypothesise that his occupation which makes use of frequent contractions of leg muscles led to increased blood flow and preferentially directed blood-borne bacteria to localise in both legs. We have also characterised the pathogen with regards to its hypermucoviscous phenotype, capsular type, virulence genes and phylogeny.

Unstable posterior acetabular fractures: Early results of delayed reduction and fracture fixation using the Kocher-Langenbeck approach with trochanteric flip osteotomy

@#<p style="text-align: justify;">Unstable posterior acetabular fractures resulting from high energy trauma present major challenges to any orthopedic surgeon especially if the treatment has been delayed.<br /><strong>OBJECTIVE:</strong> The purpose of this paper is to describe the early results of delayed treatment of a series of patients with posterior acetabular fractures with concomitant hip dislocations, surgically approached using the Kocher-Langenbeck with a trochanteric flip osteotomy.<br /><strong>METHODS:</strong> Five (5) male patients (mean age 35.6 years, range 23-58 years) who sustained unstable posterior acetabular fractures, underwent surgical treatment using the Kocher-Langenbeck approach with the trochanteric flip osteotomy, during the period of May 2014 to October 2015. Clinical and radiographic evaluations of each patient were performed, while complications were documented.<br /><strong>RESULTS:</strong> Mean follow-up was 8 weeks (range 2-12 weeks). There was adequate exposure of the posterior and superior acetabulum in all patients. Post-operative radiographs in four of five patients were graded "anatomic" while hip range of motion of these four patients averaged 78.7% of the uninjured hip. One patient with "poor" reduction underwent a second operation to reserve a failure of the initial fixation using the same surgical approach. No other complications were reported.<br /><strong>CONCLUSION:</strong> This modified approach provides adequate exposure of both posterior and superior acetabulum and also allows inspection of the articular surfaces of both acetabulum and femoral head, which are limited in the standard Kocher-Lagenbeck approach. With excellent exposure, congruent reduction can readily be achieved while permitting early hip range of motion post-surgery.</p>

Comparison of the hybrid locking plate, standard dynamic compression plate, and standard dynamic compression plate augmented with bone cement for fixation of osteoporotic humeral shaft fractures: A cadaveric biomechanical study

BACKGROUND: Studies comparing the relative strength of polymethylmethacrylate (PMMA) augmented fixation, standard plating and locked compression plate (LCP) system are few. The use of either the bone cement-augmented dynamic compression plate or the Hybrid LCP constructs may provide an additional tool for the treatment of fractures in patients with osteoporosis. METHODS: Eighteen (18) osteoporotic cadaveric humeral bones were assigned randomly to each of three groups (Dynamic Compression Plate [DCP], DCP augmented with bone cement, and the Hybrid LCP system) and tested in anterior-posterior bending and torsion/external rotation. The load to failure values were obtained and the results for each specimen compared. RESULTS: Significant differences were observed between the standard DCP and Hybrid LCP group (p-value=0.012), and in the cement-augmented and Hybrid LCP group (p-value=0.099) in torsion/external rotation loading. No significant difference was observed between the standard DCP and bone-cement augmented group (p-value=0.248). No significant difference was observed among the three groups in terms of stiffness (p-value=0.3868) in the four-point anterior-posterior bending modality. Screw pull-out of the implant was observed only in the regular DCP group in torsion/external rotation loading stress. CONCLUSION: Significant differences were seen between the three constructs in torsion/external rotation but not in anterior-posterior four-point bending. Bone failure, but not screw pull-out, was seen in the Hybrid LCP and bone cement-augmented DCP groups in torsion. This study showed that the LCP system and the bone cement-augmented constructs may provide greater screw purchase to the osteoporotic humerus.