Spanish National Hip Fracture Registry (RNFC): analysis of its first annual report and international comparison with other established registries.

Hip fracture registries have helped improve quality of care and reduce variability, and several audits exist worldwide. The results of the Spanish National Hip Fracture Registry are presented and compared with 13 other national registries, highlighting similarities and differences to define areas of improvement, particularly surgical delay and early mobilization. INTRODUCTION: Hip fracture audits have been useful for monitoring current practice and defining areas in need of improvement. Most established registries are from Northern Europe. We present the results from the first annual report of the Spanish Hip Fracture Registry (RNFC) and compare them with other publically available audit reports. METHOD: Comparison of the results from Spain with the most recent reports from another ten established hip fracture registries highlights the differences in audit characteristics, casemix, management, and outcomes. RESULTS: Of the patients treated in 54 hospitals, 7.208 were included in the registry between January and October 2017. Compared with other registries, the RNFC included patients ≥ 75 years old; in general, they were older, more likely to be female, had a worse prefracture ambulation status, and were more likely to have extracapsular fractures. A larger proportion was treated with intramedullary nails than in other countries, and spinal anesthesia was most commonly used. With a mean of 75.7 h, Spain had by far the longest surgical delay, and the lowest proportion of patients mobilized on the first postoperative day (58.5%). Consequently, development of pressure ulcers was high, but length of stay, mortality, and discharge to home remained in the range of other audits. CONCLUSIONS: National hip fracture registries have proved effective in changing clinical practice and our understanding of patients with this condition. Such registries tend to be based on an internationally recognized common dataset which would make comparisons between national registries possible, but variations such as age inclusion criteria and follow-up are becoming evident across the world. This variation should be avoided if we are to maximize the comparability of registry results and help different countries learn from each other's practice. The results reported in the Spanish RNFC, compared with those of other countries, highlight the differences between countries and detect areas of improvement, particularly surgical delay and early mobilization.

Cost of osteoporotic hip fracture in Spain per Autonomous Region. / Coste de la fractura de cadera osteoporótica en España por comunidad autónoma.

OBJECTIVE: We estimated the health resource utilization (HRU) and associated costs during the 12months after a first osteoporotic hip fracture (OHF) in six Spanish Regions. METHODS: Observational, prospective study including patients ≥65years-old hospitalized due to a first OHF in: Andalusia, Catalonia, Valencian Community, Galicia, Madrid and the Basque Country. HRU related to OHF, quality of life and patient autonomy were collected, and HRU-associated costs were estimated. RESULTS: Four hundred and eighty-seven patients (mean age: 83.1years, 77% women) were included, with demographic characteristics that were similar across the Regions. Mean hospital stay was longest in Madrid and Galicia (women/men: 15.0/18.6 and 16.9/12.6days, respectively) and shortest in Andalusia and the Valencian Community (8.2/7.2 and 8.4/9.4days). There were more rehabilitation sessions and formal home care days in Catalonia and Madrid (women/men: 16/21 and 17/29 sessions; 19/20 and 30/27days) and fewer in Andalusia and Galicia (4/1 and 3/0 sessions; 3/1 and 1/0days). Mean HRU costs were higher in Madrid and lower in Andalusia (women/men: 12,321€/12,297€ and 7,031€/6,115€, respectively). CONCLUSIONS: OHF place a large burden on Spanish Regional Health Systems, including high economic costs. We found notable differences in mean costs across the Regions, mainly caused by the differential length of the first hospital stay and the outpatient care in subsequent months. These differences may be associated with differences in surgical delay. A national consensus on the management of OHF is desirable; moreover, agreeing common guidelines could have major socio-economic and healthcare benefits.

Experimental validation of finite elements model in hip fracture and its clinical applicability. / Validación experimental de un modelo de análisis de elementos finitos en fractura de cadera y su aplicabilidad clínica.

Fracture of the proximal extremity of the femur is the subject of research interest. The complexity of the bone framework and the structural inefficiency associated with ageing leave many variables yet to be understood from an experimental perspective. However, there is no clearly defined structural and biomechanical research model for hip fracture. The hypothesis of this paper is that it is possible to create a computational experimentation model that characterises the bone of the proximal extremity of the femur as a heterogeneous material from directly translating the mechanical parameters obtained from anatomical experimentation specimens. MATERIAL AND METHOD: An experimental paper comparing real experimentation on cadavers and a numerical model based on finite element analysis (FEA). The variables uses were: the start point of the fracture, propagation of the fracture, progressive load and maximum load until fracture. The real mechanical parameters obtained from the anatomical specimens were translated to the computational model based on the relationship between the Hounsfield units of the high resolution CAT scan and the bone mineral density of each virtual element, whereas the propagation of the fracture was modelled by the research team's own computational design, reducing the mechanical properties of the damaged elements as the fracture line advanced. RESULTS: The computational model was able to determine the start point of the fracture, with a slight tendency towards anatomical medialisation of this point compared to what happened experimentally. The degree of correlation was very high on comparing the real value of progressive deformation of the samples compared to that obtained by the computational model. Over 32 points analysed, a slope of 1.03 in lineal regression was obtained, with a relative error between the deformations of 16% and a Pearson's coefficient of R2=.99. The computational model slightly underestimated the maximum fracture load, with a relative error of approximately 10%. CONCLUSION: The FEA computational model developed by this multi-disciplinary research team could be considered, as a whole, a complete FEA model of the proximal extremity of the femur with future clinical applicability since it was able to simulate and imitate the biomechanical behaviour of human femurs contrasted with a traditional experimental model made from anatomical specimens. On this basis, qualitative and quantitative interactions can be assessed which consolidate it as a powerful computational experimentation test bench for the human proximal femur.

Regional variability in changes in the incidence of hip fracture in the Spanish population (2000-2012).

UNLABELLED: The objective is to analyse the evolution of the incidence of hip fracture in the female population of Spain from 2000 to 2012 and to establish the possible changes which may have been seen over this period of time, including the trends in the different regions of the country. INTRODUCTION: Fragility-related hip fractures are considered to be the fractures of greatest significance to public health due to their high degree of morbidity and mortality. The change in their incidence, both in absolute values and when adjusted for age, is the subject of debate. The objective of this article is to describe the changes in the rates of hip fracture in Spain by autonomous community between the years 2000 and 2012. METHODS: Using the data from the Spanish Minimum Basic Data Set, in which are all the recorded cases of women with a principal diagnosis of hip fracture, the incidence rates by age group and by autonomous community were obtained. Poisson distribution or negative binomial regressions were carried out to estimate the average annual change over the time period analysed. RESULTS: There have been statistically significant changes in the trends of rates of incidence for all age groups of women over 65 years of age. The annual reduction was 2.2% for women of 65-74 years of age and less for those between 75 and 84. The rates of incidence for those over 85 increased annually by 0.58%. CONCLUSIONS: Hip fractures continue to increase in absolute numbers, although if the rates are adjusted for age, a downward trend is seen in certain age groups. These findings have various origins, although in the absence of great changes in population structure, we believe that drug treatments for osteoporosis may play a role. There is variability in the change in incidence of hip fractures in different parts of the country. Further studies are required to be able to identify the causes.

Comparison of fondaparinux with low molecular weight heparin for venous thromboembolism prevention in patients requiring rigid or semi-rigid immobilization for isolated non-surgical below-knee injury.

BACKGROUND: In several small studies, anticoagulant therapy reduced the incidence of venous thromboembolism (VTE) in patients with isolated lower-limb injuries. OBJECTIVES: To compare the efficacy and safety of fondaparinux 2.5 mg (1.5 mg in patients with a creatinine clearance between 30 and 50 mL min(-1) ) over nadroparin 2850 anti-factor Xa IU. PATIENTS AND METHODS: In this international, multicenter, randomized, open-label study, patients with an isolated non-surgical unilateral below-knee injury having at least one additional major risk factor for VTE and requiring, in the Investigator's opinion, rigid or semi-rigid immobilization for 21-45 days with thromboprophylaxis up to complete mobilization received subcutaneously once-daily either fondaparinux or nadroparin. The primary efficacy outcome was the composite of VTE (symptomatic or ultrasonographically detected asymptomatic deep vein thrombosis of the lower limb or symptomatic pulmonary embolism) and death up to complete mobilization. The main safety outcome was major bleeding. RESULTS: We randomized 1349 patients (mean age 46 years): 88.7% had a bone fracture, and 83.8% had a plaster cast fitted (mean duration of immobilization, 34 days). The primary efficacy outcome occurred in 15 of 584 patients (2.6%) in the fondaparinux group and 48 of 586 patients (8.2%) in the nadroparin group (odds ratio, 0.30; 95% confidence interval [CI], 0.15-0.54; P < 0.001). A single major bleed was experienced by fondaparinux-treated patients and none by nadroparin-treated patients. These results were maintained up to the end of follow-up. CONCLUSIONS: Fondaparinux 2.5 mg day(-1) may be a valuable therapeutic option over nadroparin 2850 anti-FXa IU day(-1) for preventing VTE after below-knee injury requiring prolonged immobilization in patients with additional risk factors.

Incidencia y factores de riesgo de luxación tras artroplastias totales de cadera con sistema acetabular de cerámica / Incidence and risk factors of dislocation after total hip replacement with a ceramic acetabular system

Objetivos. Este estudio analiza retrospectivamente la incidencia de luxación y sus factores de riesgo en una serie multicéntrica de artroplastias totales de cadera (ATC) con sistema acetabular Trident® de cerámica. Material y método. Se analizan frente a un grupo control los casos de luxación encontrados en una serie de 401 ATC llevadas a cabo con el sistema acetabular Trident® de cerámica en 10 hospitales españoles entre los años 1998 y 2004, con un seguimiento medio de 5,08 años. Se evaluó la influencia de diferentes variables, generales, clínicas y quirúrgicas, y se realizó un análisis asistido por ordenador de las variables radiográficas posiblemente implicadas en el riesgo de luxación. Resultados. La incidencia de luxación en el total de la serie fue del 1,75%, por debajo de las tasas de incidencia en series analizadas en las que se usan otro tipo de pares protésicos. Los factores de riesgo de luxación más importantes encontrados han sido los ángulos de abducción e inclinación acetabular (p = 0,016), aunque también se ha apreciado una tendencia a la luxación a medida que aumenta la edad del paciente y el grado ASA. Conclusión. A la hora de realizar una ATC de par cerámica-cerámica el ángulo de abducción acetabular parece ser el factor más importante a tener en cuenta para prevenir la luxación. Tamaños de cabeza femoral mayores de 32mm podrían actuar como factor limitante del riesgo de luxación protésica. Variables clínicas como la edad del sujeto o el grado ASA muestran su tendencia como factores de riesgo de luxación protésica (AU)

Objectives. This study retrospectively analysed the incidence of dislocation and its risk factors in a multicentre series of total hip replacement with a Trident® ceramic acetabular system. Material and method. Cases of dislocation in a series of 401 total hip replacements performed using a Trident® ceramic acetabular system in 10 Spanish hospitals between the years 1998 and 2004, with a mean follow-up of 5.08 years, were analysed and compared to a control group. The influence of different variables, general, clinical and surgical was evaluated and a computer assisted analysis was made of the radiographic variables possibly involved in the risk of dislocation. Results. The incidence of dislocation in the whole series was 1.75%, lower than incidence rates in series analysed that used other types of artificial joints. The most important dislocation risk factors found were the abduction angles and acetabular inclination (P=.016), although there was also tendency to dislocation as the patient age and the ASA level increased. Conclusion. When performing a ceramic-ceramic joint total hip replacement, the angle of acetabular abduction appears to be the most important factor to take into account to prevent dislocation. Femur head sizes greater than 32mm could act as a limiting factor of the risk of artificial joint dislocation. Clinical variables, such as the age of the subject or ASA level show a tendency as a risk of artificial joint dislocation (AU)

Daily or monthly ibandronate prevents or restores deteriorations of bone mass, architecture, biomechanical properties and markers of bone turnover in androgen-deficient aged rats.

AIM: The aim of this study was to investigate the effects of the bisphosphonate ibandronate (IBN) in a male osteoporosis animal model. METHODS: Two studies were performed in 9-month-old orchidectomised (ORX) or sham-operated rats. In prevention study, subcutaneous IBN was administered daily (1 µg/kg) or monthly (28 µg/kg every 28 days) starting on day of surgery for 5 months. In treatment study, the same treatment started 6 months after ORX. After sacrifice, bone analyses by dual-energy X-ray absorptiometry, 3-dimensional micro-computed tomography, and 3-point bending were performed in femora or vertebrae. Serum tartrate-resistant acid phosphatase 5b (TRAP-5b) and aminoterminal propeptide of collagen I (PINP) were analysed for resorption and osteocalcin (BGP) for bone formation. RESULTS: In both studies, ORX resulted in significant femoral and vertebral bone loss and microarchitectural deterioration after 5 months of ORX, and became more pronounced after 11 months. Biomechanical strength was also decreased. Serum levels for TRAP-5b and BGP increased while PINP levels were reduced or unchanged. Both daily and monthly IBN prevented or even restored ORX-induced changes in both studies, with the intermittent regimen showing a improvement in efficacy with respect to many of the biomechanical parameters.

Comparative effects of 17beta-estradiol, raloxifene and genistein on bone 3D microarchitecture and volumetric bone mineral density in the ovariectomized mice.

UNLABELLED: This study assessed the effect of estradiol, raloxifene and genistein on the preservation of bone 3D-microarchitecture and volumetric bone mineral density (vBMD) in the ovariectomized mouse model. Our results indicated that raloxifene was more effective in preserving bone ovariectomized-induced changes, the advantage being concentrated in both bone microarchitecture and vBMD. INTRODUCTION: This study assessed the effect of different estrogen receptor (ER) agonists on the preservation of bone 3D-microarchitecture and volumetric bone mineral density (vBMD) in the ovariectomized (OVX) mouse model. METHODS: Twelve-week-old female C57BL/6 mice were randomly assigned to one of five groups: (1) SHAM-operated + vehicle; (2) OVX + vehicle; (3) OVX + 17beta-estradiol (5 microg/kg); (4) OVX + raloxifene (1 mg/kg); (5) OVX + genistein (25 mg/kg), during 4-weeks. Bone microarchitecture and trabecular, cortical and total vBMD of distal femur were imaged by ex vivo microcomputed tomography (micro-CT). RESULTS: Ovariectomy produced a global deterioration involving both trabecular and cortical 3D-microarchitecture and vBMD. Raloxifene maintained both microarchitecture and vBMD, whereas estradiol prevented deterioration of some microstructural parameters, such as trabecular thickness (Tb.Th), trabecular bone pattern factor (Tb.Pf), and cortical periosteal perimeter (Ct.Pe.Pm), but did not completely block the loss in vBMD. Mice treated with genistein exhibited the less favourable profile in both vBMD and microstructural parameters preserving only cross-sectional bone area (B.Ar) and Ct.Pe.Pm in cortical bone. CONCLUSION: Our data indicate that, at the selected doses, raloxifene was more effective in preserving bone OVX-induced changes than either estradiol or genistein, the advantage being concentrated in both bone microarchitecture and vBMD.