Q J Med 2000; 93: 501-506
© 2000 Association of Physicians
Review |
Management of osteoporosis in patients with hip fractures
1 From the Department of Medicine (Geriatrics), University of Newcastle upon Tyne, 2 Department of Medicine for the Elderly, North Tyneside General Hospital, North Shields, 3 Department of Rheumatology, Dryburn Hospital, Durham, 4 Department of Rheumatology, Wansbeck General Hospital, Ashington, 5 Department of Rheumatology, Sunderland District General Hospital, 6 Department of Rheumatology, Hartlepool General Hospital, 7 Department of Rheumatology, South Cleveland Hospital, Middlesbrough, 8 Department of Rheumatology, Queen Elizabeth Hospital, Gateshead, and 9 Department of Geriatric Medicine, South Tyneside District Hospital, South Shields, UK
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Introduction |
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 Top Introduction Scale of the problemRisk factors for hip...Management of patients with...Investigation of patients with...Treatment for osteoporosis in...Reduction of fallsReduction of impact of...Management of the individual...References |
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Hip fractures are a major cause of excess mortality, morbidity and health and social service expenditure in elderly people.1 Patients who survive hip fractures are at high risk of further fracture,2,3 yet most receive no treatment for osteoporosis or advice on reducing falls. A number of guidelines on the management of osteoporosis have been published, but these contain little specific advice on the management of patients with hip fracture.4–6 A group of physicians from the North-East of England interested in osteoporosis has therefore met on a number of occasions, to develop practical advice on the management of osteoporosis in patients with hip fractures.
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Scale of the problem |
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TopIntroductionScale of the problemRisk factors for hip...Management of patients with...Investigation of patients with...Treatment for osteoporosis in...Reduction of fallsReduction of impact of...Management of the individual...References |
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Bone is lost with advancing age in both men and women, leading to an increased risk of fractures after minimal trauma. The major osteoporotic fractures are those of the forearm, vertebral body and hip. Each year, about 60 000 hip fractures occur in the UK, causing excess mortality, substantial morbidity and vast health and social service costs. The lifetime risk of hip fracture in the UK been estimated at 14% for a 50-year-old woman and 3% for a 50-year-old man,1 although these figures may be underestimates, because of declining mortality in the elderly.7 The excess mortality after hip fracture is 10–20%,1,8,9 which may be related in part to co-morbidity. There is also considerable morbidity after hip fractures, as 25–50% of patients become more dependent, many of whom require placement in a residential or nursing home.10, 11The annual cost of osteoporotic fractures in the UK has been estimated at £942m, of which 87% is due to hip fractures.12
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Risk factors for hip fracture |
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TopIntroductionScale of the problemRisk factors for hip...Management of patients with...Investigation of patients with...Treatment for osteoporosis in...Reduction of fallsReduction of impact of...Management of the individual...References |
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The risk of hip fractures is determined not only by bone mineral density (BMD), but also by factors associated with physical frailty and an increased risk of falls.13–15 Studies show an increased risk of hip fracture with causes of secondary osteoporosis, such as oral corticosteroid therapy, thyroid disease and hypogonadism, and with conditions associated with falling, such as previous stroke, Parkinson's disease and dementia.14,16–19 Biochemical and histological studies suggest that vitamin D deficiency and osteomalacia are also risk factors for hip fractures.20,21
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Management of patients with hip fracture |
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TopIntroductionScale of the problemRisk factors for hip...Management of patients with...Investigation of patients with...Treatment for osteoporosis in...Reduction of fallsReduction of impact of...Management of the individual...References |
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The management of patients with hip fractures includes the surgical fixation of the fracture and subsequent rehabilitation to allow the optimal recovery of functional capacity. Although there is considerable interest in the role of orthogeriatric units in the rehabilitation of patients after hip fracture, a recent Cochrane review found no significant difference in outcome with co-ordinated multidisciplinary rehabilitation supervised by a geriatrician, compared with standard orthopaedic care.22 There was however a trend towards a reduction in death, institutional care and functional deterioration in patients undergoing co-ordinated multidisciplinary rehabilitation.22 Furthermore, a randomized controlled trial showed that accelerated rehabilitation was more cost-effective than standard care and rehabilitation.23 It is therefore desirable that geriatricians should be involved in the assessment and rehabilitation of patients with hip fractures, although the optimal model of care remains unclear, and may vary according to local circumstances.
Studies have shown malnutrition in patients admitted with hip fracture, which is aggravated by the catabolic response to injury, surgery and any post-operative complications.24,25 Dietary supplementation or nasogastric tube feeding improves outcome, shortens hospital stay and decreases mortality, particularly in very thin patients.26,27 Nutritional assessment should therefore be performed in all patients with hip fracture, to identify those who would benefit from nutritional support.
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Investigation of patients with hip fracture |
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TopIntroductionScale of the problemRisk factors for hip...Management of patients with...Investigation of patients with...Treatment for osteoporosis in...Reduction of fallsReduction of impact of...Management of the individual...References |
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In view of the rapid bone loss after hip fracture28,29 and the increased risk of recurrence,2,3 all patients should undergo a ‘falls and osteoporosis’ assessment. This could be performed by a geriatrician or other interested physician, depending on local circumstances. Underlying causes of falls should be sought by medical assessment, including tilt-table testing and carotid sinus massage where there is a history of unexplained falls, as a significant number of such patients have carotid sinus hypersensitivity.30 Secondary causes of osteoporosis should also be identified from medical history, examination and investigations, as treatment of conditions such as hyperthyroidism, hyperparathyroidism and hypogonadism increases bone density.31–34
Routine bone profile is probably worthwhile, as hypocalcaemia and hypophosphataemia suggest the possibility of osteomalacia, although these measurements lack specificity or sensitivity for this diagnosis.35 Estimation of serum 25-hydroxyvitamin D and intact parathyroid hormone estimation is potentially useful in excluding the diagnosis of vitamin D deficiency in patients with limited sunlight exposure, but is probably unnecessary if calcium and vitamin D supplementation is planned.
Hyperthyroidism is a risk factor for hip fractures,14 but is not always associated with the classical signs or symptoms of thyrotoxicosis.36 Thyroid function tests may therefore be useful in excluding the diagnosis of hyperthyroidism, but should be performed after the patient has recovered from the fracture and subsequent surgery.
Up to 50% of elderly men with hip fractures have biochemical evidence of hypogonadism,18,37 which may be due in part to altered hypothalamic-pituitary-gonadal function following the fracture and surgery. Testosterone replacement improves bone density and increases muscle mass in hypogonadal men with osteoporosis,33,34 but these benefits may be offset by adverse effects on the risk of prostatic or heart disease.38 Testosterone treatment should be considered in all men with a low morning serum testosterone several months after hip fracture, but the final decision will depend on an evaluation of the potential risks and benefits in the individual patient.
Measurement of hip bone density by dual energy X-ray absorptiometry is currently the best method of assessing the risk of hip fracture.39 Such measurements are of limited value in the diagnosis of osteoporosis in elderly patients with hip fractures, as the vast majority will have reduced bone density,40,41 so the results are unlikely to influence management. Nevertheless, bone density measurements may be used to confirm the diagnosis and severity of osteooporosis in younger patients and to monitor the response to treatment in selected patients.6
Investigations for secondary causes of osteoporosis and bone density measurements are probably most appropriate in younger (<75 years), fitter patients with hip fracture, as they are more likely to have on underlying cause of accelerated bone loss. They may also benefit more from specific treatment for osteoporosis, because of their greater life expectancy.
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Treatment for osteoporosis in patients with hip fracture |
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TopIntroductionScale of the problemRisk factors for hip...Management of patients with...Investigation of patients with...Treatment for osteoporosis in...Reduction of fallsReduction of impact of...Management of the individual...References |
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All patients with hip fracture should be given general advice on lifestyle measures to decrease further bone loss, including eating a balanced diet rich in calcium, moderating tobacco and alcohol consumption, and, if possible, maintaining regular physical activity and exposure to sunlight. As bone loss from the femoral neck continues into old age in both men and women,42 and accelerates after hip fracture,28,29 specific treatment for osteoporosis should be considered in all patients with hip fracture. Unfortunately, no secondary prevention studies of the treatment of osteoporosis in elderly patients with hip fractures have yet been published, although a number of controlled trials have examined the management of osteoporosis in older people.
Studies of hormone replacement therapy (HRT) have been performed in older postmenopausal women with established osteoporosis and vertebral fractures (mean age 68 years), which show a beneficial effect on spine and hip bone density and vertebral deformation.43,44 HRT may therefore be useful in the younger woman with hip fracture, but is unlikely to be acceptable in older women.
Randomized controlled trials of bisphosphonates in the management of osteoporosis have included women up to the age of 75 years in the case of cyclical etidronate45–47 and 85 years with alendronate,48–50 with no apparent attenuation of effect with advancing age.50 The Fracture Interventional Trial showed that alendronate decreased the incidence of hip fractures in women with established osteoporosis by 51%,49 but there are no published studies specifically examining the effect of alendronate in the very elderly or those with hip fractures. There are no interventional studies showing a reduction in hip fracture incidence with cyclical etidronate, but epidemiological data using the GP Research Database shows a 44% reduction in hip fractures with cyclical etidronate in women over the lumbar spine and femoral neck and to decrease the incidence of vertebral and non-vertebral fractures in women with osteoporosis.52 Bisphosphonates may therefore be useful in the management of patients with hip fractures.
Calcium and vitamin D supplementation may be the most appropriate treatment for elderly patients with hip fractures, as vitamin D deficiency and secondary hyperparathyroidism contribute to bone loss with advancing age. Furthermore, housebound and frail elderly people are at greatest risk of vitamin D deficiency and hip fractures. In a French study in nursing homes and apartment blocks for the elderly, 800 IU vitamin D3 and 1.2 g elemental calcium daily reduced the risk of hip fracture by 43%.53 A smaller American study of older men and women living at home demonstrated that 700 IU vitamin D3 and 500 mg elemental calcium daily had a modest beneficial effect in bone density and decreased the incidence of non-vertebral fractures.54 It is unclear if the benefits of treatment seen in these studies were due to vitamin D, calcium or the combination of both, but a Finnish study showed that an annual i.m. injection of 150 000–300 000 IU vitamin D decreases the risk of fractures in elderly people by 25%.55 In contrast, a Dutch study showed a small increase in hip bone density with 400 IU vitamin D3 daily, but no effect on the incidence of hip fractures in elderly people.56
The Medical Research Council (MRC) has recently agreed to fund a multicentre study of the secondary prevention of osteoporotic fractures in elderly people. Over 6000 men and women presenting with an osteoporotic fracture will be randomized to receive calcium, vitamin D, calcium and vitamin D or double placebo. This study will examine the effect of treatment on the incidence of subsequent fractures, and will hopefully establish if both calcium and vitamin D supplementation in required. Pending the results of the MRC study, it would probably be prudent to use the combination of calcium and vitamin D, providing at least 1000 mg calcium and 800 IU vitamin D daily in the management of frail elderly patients with hip fractures.
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Reduction of falls |
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TopIntroductionScale of the problemRisk factors for hip...Management of patients with...Investigation of patients with...Treatment for osteoporosis in...Reduction of fallsReduction of impact of...Management of the individual...References |
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Risk factors for falling are divided into intrinsic factors, including poor vision, neurological disease and medication, and extrinsic or environmental factors, such as trailing wires, loose carpets and ill-fitting footwear. A number of randomized controlled trials have assessed the effect of modifying these risk factors for falling. Rubenstein showed that a standard geriatric assessment led to significantly fewer admissions to hospital, but only a non-significant 9% reduction in falls.57 An English study investigated whether health visitors could reduce the number of fractures in elderly people, by giving advice in nutrition, physical fitness and modifying intrinsic and extrinsic risk factors for falling.58 Over the four year of the study, there was no significant difference in the prevalence of fractures in the intervention group (5%) or control group (4%).
In a randomized controlled study in 301 elderly patients at risk of falls, the intervention group underwent geriatric assessment with modification of risk factors for falling, whereas the control group had the usual health care and social visits. Over the following year, 35% of the intervention group had falls, compared to 47% in the control group.59 Although the difference in the two groups was statistically significant, the study was too small to detect an effect on fracture incidence. The PROFET study randomized 397 elderly patients attending an Accident and Emergency Department after a fall to undergo a detailed medical and occupational therapy assessment or to receive usual care. During the 12 months of study, was a 61% reduction in falls and 50% fewer fractures in the intervention group, although the latter was not statistically significant.60
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Reduction of impact of falls |
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TopIntroductionScale of the problemRisk factors for hip...Management of patients with...Investigation of patients with...Treatment for osteoporosis in...Reduction of fallsReduction of impact of...Management of the individual...References |
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An alternative approach to fracture prevention is to decrease the impact of falls using external hip protectors. A Danish study randomized elderly residents of nursing home to receive hip protectors or to serve as controls. Over the 12 month study there was a reduction in hip fractures of over 50% in those using the hip protectors.61 Other studies also show a reduction in hip fractures with external hip protectors.62,63 Although these results are impressive, current hip protectors are bulky and uncomfortable, leading to poor compliance.64 New work is focusing on the development of more acceptable devices.
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Management of the individual patient |
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TopIntroductionScale of the problemRisk factors for hip...Management of patients with...Investigation of patients with...Treatment for osteoporosis in...Reduction of fallsReduction of impact of...Management of the individual...References |
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A practical approach to the management of patients with hip fracture is shown in Figure 1
. Measures to decrease bone loss and reduce the risk of falls should be taken in all patients, and the use of external hip protectors considered in those who continue to fall. The authors of this review consider that patients with hip fractures fall into two broad groups, which may modify the approach to management. The first group comprises mainly elderly, frail patients, many of whom were immobile or housebound before fracture. Patients in the second group are generally younger and were previously mobile and independent.
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Patients in the first group have limited life expectancy, so it is probably inappropriate to perform extensive investigations to exclude secondary causes of osteoporosis or to request bone density measurements. These patients may benefit more from calcium and vitamin D supplementation than other therapeutic interventions, as they are likely to have vitamin D deficiency.
Patients in the second group would benefit from more active investigation and therapeutic intervention, as life expectancy and quality of life may be improved by decreasing the risk of further fractures. It is therefore recommended that investigations to exclude secondary causes of osteoporosis are performed in this group. Bone density measurements should also be considered, to assess the future risk of fracture and monitor the response to treatment. The choice of treatment will depend on a number of factors, including biological age, cognitive function, likely compliance and patient preference. The options include HRT in younger postmenopausal women, testosterone replacement in hypogonadal men, bisphosphonates and calcium and vitamin D supplementation.
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Acknowledgments |
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This review is based on a series of meetings, supported by an unrestricted educational grant from Procter and Gamble Pharmaceuticals. The views and opinions expressed are those of the named authors.
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Notes |
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Address correspondence to Dr R.M. Francis, Musculoskeletal Unit, Freeman Hospital, Newcastle upon Tyne, NE7 7DN. e-mail: rmfrancis{at}compuserve.com
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References |
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TopIntroductionScale of the problemRisk factors for hip...Management of patients with...Investigation of patients with...Treatment for osteoporosis in...Reduction of fallsReduction of impact of...Management of the individual...References |
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