Osteoporotic Hip Fractures in the Elderly- A Growing Management Challenge - HDE Atkinson June 2005

Authors:   Henry Dushan Atkinson,   Aleksandar Lešić, Marko Bumbaširević

Institute for Orthopaedic Surgery and Traumatology, Belgrade School of Medicine, Clinical Centre of Serbia, Belgrade, Serbia. June 2005.

Summary

2000-2010 was declared “The Bone and Joint Decade” by the World Health Organization and United Nations, and this was further endorsed by the governments of 58 countries, with the purpose of promoting awareness of musculoskeletal disorders; amongst these, osteoporosis and its associated fragility fractures were acknowledged as a major healthcare problem, especially in view of a steadily aging global population.

Hip fractures are probably the most serious consequence of osteoporosis, and a leading cause of morbidity and mortality in the older population. With this in mind, we reviewed local data from Belgrade, Serbia Montenegro as well as international published data on the incidence rates of cervical and trochanteric hip fractures in adults aged 50 years and over. To compare data from the different population groups, the specific incidence rates were standardized according to the 1985 US white population.

The literature reported a female predominance and a higher incidence of trochanteric over cervical types of hip fracture. Hip fractures occurred more frequently in the white populations of the USA, Western Europe and Scandinavian countries, while lower rates were recorded in Far Eastern and Black populations. There was an increase in the incidence rates of hip fractures with time, during the observed periods in most studies, with an almost exponential increase in hip fracture rates with increasing patient ages, especially over the age of 60 years.

            Regression analyses predict that compared to 1990 there will be a 250% increase in the incidence of hip fractures in Belgrade by 2021, with a worldwide epidemic increasing from an annual 1.66 million patients in 1990 to a projected annual 6.26 million hip fracture patients in 2050. This increasing rate of hip fracture incidence with increasing age is strongly associated with increases in the incidence of osteoporosis. Thus, with an aging world population, osteoporosis and hip fractures will become a real global burden in the next century, especially in developing countries.

Key words

Hip fracture, Epidemiology, Incidence rate, International comparison, Osteoporosis

Introduction

We are currently midway through the Internationally endorsed “Bone and Joint Decade 2000-2010” (1), a Movement created to raise awareness of the growing burden of musculoskeletal disorders on society, healthcare systems and the individual, as well as to promote their prevention and treatment. Osteoporosis and its associated fragility fractures have now been recognized as representing a major global healthcare problem, possibly second only to cardiovascular disease (2). Indeed lifetime risk of sustaining an osteoporotic fracture is estimated to be as high as one in three women and one in eight men over the age of 50 (2).

Hip fractures are probably the most serious consequence of osteoporosis, and a leading cause of morbidity and mortality in the older population, with half of previously independent individuals becoming partly or wholly dependent, and 5-20% dying within one year following injury. (3)

The incidence of hip fractures increases exponentially with age over 50 years, and as the global population steadily grows older it is predicted that hip fractures may reach epidemic levels in the future (4,5,6).

An analysis was made of all hospital records during the period 1990-2000 in Belgrade, Serbia Montenegro, in an attempt to determine the current local trends and to make predictions of the likely incidence of hip fractures over the next 20 years. These results, looking at which types of fracture would likely predominate, the gender of patients, and the absolute numbers of patients, would thereby help to determine the likely future burden on our health-care and social welfare systems (6,7).

Numbers and incidence of the hip fractures

The numbers of hip fractures treated in Belgrade hospitals over the period 1990-2000 were obtained from the registers in Belgrade’s National Health Care Center , and Gullberg's solution was used to calculate projections for the future with a rate of increase of 1% (6). There were no previous statistics from the same geographical area with which to compare the analyzed data.

It is usual to standardise such population data (6,8), and specific rates are commonly adjusted according to the 1985 US white population for all age groups and for both sexes. Thus national hip fracture incidence rates can be compared and various demographics including possible genetic-ethnic, environmental or professional associations be further analysed.

Table 1 shows female/male ratios and standardized hip fracture incidence rates per 100,000 adults per year, for different populations. The highest incidence rates are reported by Norway, Sweden, USA, Australia, Switzerland (9,10,11,12,13); incidence rates in Italy, France, Kuwait, Japan and Great Britain (8,12,14,15) are lower, and similar to our local data from Belgrade; while the lowest rates are recorded in China and Korea (8,16).  

The increase in incidence rates for the Belgrade population according to age and sex is shown in Figure 1. Cervical and trochanteric fractures show a similar increase with age (Figure 2 and 3), and there is a rapid increase in incidence rates above the age of 50 years, similar to published data (7,8,17).

Although the incidence of hip fractures increases with age in all ethnic groups (17), it occurs later in Blacks and Asians. This is maybe partially related to differences in bone mass and density (7,18,19); as Black populations have higher levels. However, Japanese have a lower incidence of hip fractures than would be expected from their relatively low bone mineral content, indicating that other factors may be involved; such as better neuromuscular function with traditional exercises or a lower posture (7).

Female-male and cervico-trochantric ratios

The literature suggests a female predominance of hip fractures, especially in the older age groups, where they comprise 66% to 78% of fracture patients; with a female to male proportion of around 2:1 (3, 20,21,22,23). However, some Far Eastern populations have reverse findings (24,25). Our hip fracture population comprised 67.4% females and 32.6% males. There are some differences between the various studies concerning the cervico-trochanteric ratio, though trochanteric fractures are commoner in most (20,22,23,26). Our study data had a higher rate of trochanteric fractures; 53% compared with 47% cervical fractures. The type of predominating hip fracture is   important, as cervical and trochanteric fractures are two quite different diagnoses and are managed differently surgically; therefore having different resource implications. (Figure 4 Preoperative cervical hip fracture and postoperative xrays with Hemiarthroplasty in situ. Figure 5   Preoperative trochanteric hip fracture and postoperative xrays showing fixation with a Dynamic Hip Screw).

Age

Patients in the West tended to be older (78-82 and 71-82 years for females and males respectively) than in the East (62-67 years). In our population the mean age was 72 for females and a surprisingly low 59 years for males.

Mechanism of injury

In most cases the hip fracture was caused by a fall from standing height onto a level surface (26,27). In our series 65.6% of all hip fractures occurred as a result of such a fall in the home, yard or street. Elderly hip fractures were most often the result of low energy trauma (70.3%), while in the younger patients the fractures were more commonly caused by a high energy trauma (e.g. traffic accidents in 59.7%).

Time trends in hip fracture incidence

The increase in the incidence rates of hip fractures in the past is often used to make worldwide projections for the next 50 years (3,6,28,29).   Using our data from the period 1990-2000, we have made similar predictions for the future (2011-2021) (Figure 6 and 7).   

When making such projections of hip fracture incidence rate increases, Gullberg et al gave five solutions (6): these ranged from the most conservative, (that there would be no increase), and increased by 1% increments up to a 4% annual increase. In Great Britain, for example, there were 46,000 hip fractures in 1985, which may increase to between 60,000 and 117,000 by 2025, depending on the calculated increment. According to these projections, the global annual number of hip fractures may rise from 1.6 million in 1990 to 6.26 million in 2050; thus generating an enormous burden for Orthopedic Surgeons and Health Care systems(6). Indices for the predicted increases of the number of hip fractures in Europe are given in Table 2. We chose to calculate our data using the intermediate solution of a 1% increase, thus producing a hip fracture projection index increase of 124 for males and 219 for females (6).

According to Cooper et al (29) in the next half century there will be dramatic changes in the number of hip fractures in Asia and Latin America, due to the expected increase in the elderly population. Assuming that the elderly population in Asia will double, the prediction is that their proportion of   global hip fractures will rise from 38.3% in 1990 to 63.6% in 2050. However, this prediction does not consider demographic catastrophies such as HIV/AIDS in Asia and Africa. Thus a more realistic prediction may be that Asian elderly comprise 51% of the global elderly, with consequential increases in hip fractures (6) . The population of Europe and USA is more stable, and thus population predictions are likely to be more reliable.

Final Observations

The incidence of hip fractures increases exponentially with age, and as the global population, especially in developing countries, becomes older, so the prevalence of hip fractures will increase. It is therefore important to try to establish which patients have increased risk factors for osteoporosis, and target them early with prophylactic treatment.

Contributing factors for osteoporosis and hip fractures such as low levels of physical activity, a sedentary life-style, the environment, diet, race, poor neuromuscular control and poor muscular protection due to aging and disease, have become themes of study especially in Western Europe, the USA and Scandinavian countries; as have methods of prevention such as the treatment of osteoporosis by medical (Table 2) and non-medical means, alterations in lifestyle, reduction in smoking, and alcohol consumption, avoidance of long-term corticosteroid (30) and the wearing of   “hip protectors” in the elderly (31,32,33) .

In addition many drugs, especially psychotropic drugs and those with hypotensive effects, as well as patients with polypharmacy (taking four or more drugs) may also be risk factors for hip fracture (34 ,35,36 )

Table 2 – Current medical treatments for osteoporosis (NICE and SIGN guidelines)(37,38)

            The relationship of hip fracture incidence with climatic and geographic factors remains unclear. Though sharing similar climates and standards of living, there are high rates of hip fracture in Scandinavia and the USA, while lower rates in Great Britain, Continental Europe and Japan. Australia with a much warmer climate also has high rates of hip fracture.

            It seems that ethnic origin is a dominant factor, as immigrants have similar incidence rates to that of the population in their native countries rather than to those of the new local population. Nevertheless, Whites and Asians show an increase in adjusted incidence rates for hip fractures, maybe due to growing similarities in their life-styles,   in terms of smoking, alcohol consumption, and a reduction in physical work.

            There are also differences between urban and rural populations (18,19,20). It is thought that lower levels of industrialisation and greater levels physical activity lead to greater bone strength and consequently lower hip fracture rates in rural than compared with urban areas (39).

            Despite our attempts to prevent and treat osteoporosis it is unlikely that we will ever be able to prevent all hip fractures, and indeed it appears as though the number of fractures will keep rising (3,6,39). The treatment of hip fractures is surgical in most cases, in order to enable early mobilization, provide pain relief, and prevent the well known complications of immobility (such as pneumonia, pressure sores, deep venous thrombosis); and indeed these patients often also require substantial medical support. T hus hip fractures will constitute a substantial challenge for orthopedic surgeons, physicians and healthcare systems in the future, and financial and resource preparations should be made to anticipate this.

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Table 1. Age-standardized rates of hip fractures in females and males aged 50 years and over in different populations* (per 100,000 adults).

*   from (8): Memon A., Pospula W.M., Tantawy A.Y., Abdul-Ghafar S., Suresh A., Al-Rowaih: Incidence of hip fractures in Kuwait, International Journal of Epidemiology 1998;27:860-865.

* * Standardised according to 1985 US white population

Table 2: Hip fracture projection index of increase for patients aged 50 years and older from 1990 to 2025 [according to Gullberg et al. (6)]