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

Authors: Henry Dushan Atkinson, Aleksandar Leić, Marko Bumbairević

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

Summary

2000-2010 wasdeclared The Bone and Joint Decade by the World Health Organization andUnited Nations, and this was further endorsed by the governments of 58countries, with the purpose of promoting awareness of musculoskeletaldisorders; amongst these, osteoporosis and its associated fragility fractureswere acknowledged as a major healthcare problem, especially in view of asteadily aging global population.

Hip fractures are probably the most serious consequence ofosteoporosis, and a leading cause of morbidity and mortality in the olderpopulation. Withthis in mind, we reviewed local data from Belgrade, Serbia Montenegro as wellas international published data on the incidence rates of cervical andtrochanteric hip fractures in adults aged 50 years and over. To compare datafrom the different population groups, the specific incidence rates were standardizedaccording to the 1985 US white population.

The literature reported a femalepredominance and a higher incidence of trochanteric over cervical types of hipfracture. Hip fractures occurred more frequently in the white populations ofthe USA, Western Europe and Scandinavian countries, while lower rates wererecorded in Far Eastern and Black populations. There was an increase in theincidence rates of hip fractures with time, during the observed periods in moststudies, with an almost exponential increase in hip fracture rates withincreasing patient ages, especially over the age of 60 years.

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

Key words

Hip fracture, Epidemiology, Incidence rate, Internationalcomparison, Osteoporosis

Introduction

We are currentlymidway through the Internationally endorsed Bone and Joint Decade 2000-2010(1), a Movement created to raise awareness of the growing burden ofmusculoskeletal disorders on society, healthcare systems and the individual, aswell as to promote their prevention and treatment. Osteoporosis and itsassociated fragility fractures have now been recognized as representing a majorglobal healthcare problem, possibly second only to cardiovascular disease (2).Indeed lifetime risk of sustaining an osteoporotic fracture is estimated to beas 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 ofosteoporosis, and a leading cause of morbidity and mortality in the olderpopulation, with half of previously independent individuals becoming partly orwholly 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 theglobal population steadily grows older it is predicted that hip fractures mayreach epidemic levels in the future (4,5,6).

An analysis was made of all hospital records during the period1990-2000 in Belgrade, Serbia Montenegro, in an attempt to determine thecurrent local trends and to make predictions of the likely incidence of hipfractures over the next 20 years. These results, looking at which types offracture would likely predominate, the gender of patients, and the absolutenumbers of patients, would thereby help to determine the likely future burdenon our health-care and social welfare systems (6,7).

Numbers andincidence of the hip fractures

The numbers of hip fractures treated in Belgradehospitals over the period 1990-2000 were obtained from the registers inBelgrades National Health Care Center , and Gullberg's solution was used to calculate projectionsfor the future with a rate of increase of 1% (6). There were no previousstatistics from the same geographical area with which to compare the analyzeddata.

It is usual to standardise suchpopulation data (6,8), and specific rates are commonly adjusted according tothe 1985 US white population for all age groups and for both sexes. Thusnational hip fracture incidence rates can be compared and various demographicsincluding possible genetic-ethnic, environmental or professional associationsbe further analysed.

Table 1 shows female/male ratios andstandardized hip fracture incidence rates per 100,000 adults per year, fordifferent 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 toour local data from Belgrade; while the lowest rates are recorded in China andKorea (8,16).

The increase in incidence rates forthe Belgrade population according to age and sex is shown in Figure 1. Cervicaland 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 hipfractures increases with age in all ethnic groups (17), it occurs later inBlacks and Asians. This is maybe partially related to differences in bone massand density (7,18,19); as Black populations have higher levels. However,Japanese have a lower incidence of hip fractures than would be expected from theirrelatively low bone mineral content, indicating that other factors may beinvolved; such as better neuromuscular function with traditional exercises or alower posture (7).

Female-maleand cervico-trochantric ratios

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

Age

Patients in the West tended to beolder (78-82 and 71-82 years for females and males respectively) than in theEast (62-67 years). In our population the mean age was 72 for females and asurprisingly low 59 years for males.

Mechanism of injury

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

Time trendsin hip fracture incidence

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

When making such projections of hipfracture incidence rate increases, Gullberg et al gave five solutions (6):these ranged from the most conservative, (that there would be no increase), andincreased by 1% increments up to a 4% annual increase. In Great Britain, forexample, there were 46,000 hip fractures in 1985, which may increase to between60,000 and 117,000 by 2025, depending on the calculated increment. According to these projections, the globalannual number of hip fractures may rise from 1.6 million in 1990 to 6.26million in 2050; thus generating an enormous burden for Orthopedic Surgeons andHealth Care systems(6). Indices for the predicted increases of the number of hip fractures inEurope are given in Table 2. We chose to calculate our data using theintermediate solution of a 1% increase, thus producing a hip fractureprojection index increase of 124 for males and 219 for females (6).

According to Cooper et al (29) in thenext half century there will be dramatic changes in the number of hip fracturesin Asia and Latin America, due to the expected increase in the elderlypopulation. Assuming that the elderly population in Asia will double, theprediction 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 inAsia and Africa. Thus a more realistic prediction may be that Asian elderlycomprise 51% of the global elderly, with consequential increases in hipfractures (6) . The population of Europe and USA ismore stable, and thus population predictions are likely to be more reliable.

Final Observations

The incidence of hip fracturesincreases exponentially with age, and as the global population, especially indeveloping countries, becomes older, so the prevalence of hip fractures willincrease. It is therefore important to try to establish which patients haveincreased risk factors for osteoporosis, and target them early withprophylactic treatment.

Contributing factors for osteoporosisand hip fractures such as low levels of physical activity, a sedentarylife-style, the environment, diet, race, poor neuromuscular control and poormuscular protection due to aging and disease, have become themes of studyespecially in Western Europe, the USA and Scandinavian countries; as havemethods of prevention such as the treatment of osteoporosis by medical (Table2) and non-medical means, alterations in lifestyle, reduction in smoking, andalcohol consumption, avoidance of long-term corticosteroid (30) and the wearingof hip protectors in the elderly (31,32,33) .

In addition many drugs, especiallypsychotropic drugs and those with hypotensive effects, as well as patients withpolypharmacy (taking four or more drugs) may also be risk factors for hipfracture (34 ,35,36 )

Table 2 Current medical treatments for osteoporosis (NICE and SIGNguidelines)(37,38)

Therelationship of hip fracture incidence with climatic and geographic factorsremains unclear. Though sharing similar climates and standards of living, thereare high rates of hip fracture in Scandinavia and the USA, while lower rates inGreat Britain, Continental Europe and Japan. Australia with a much warmerclimate also has high rates of hip fracture.

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

Thereare also differences between urban and rural populations (18,19,20). It isthought that lower levels of industrialisation and greater levels physicalactivity lead to greater bone strength and consequently lower hip fracturerates in rural than compared with urban areas (39).

Despiteour attempts to prevent and treat osteoporosis it is unlikely that we will everbe able to prevent all hip fractures, and indeed it appears as though thenumber of fractures will keep rising (3,6,39). The treatment of hip fractures is surgical in most cases, inorder to enable early mobilization, provide pain relief, and prevent the wellknown complications of immobility (such as pneumonia, pressure sores, deepvenous thrombosis); and indeed these patients often also require substantialmedical support. T hus hip fractures will constitute a substantial challenge for orthopedicsurgeons, physicians and healthcare systems in the future, and financial andresource preparations should be made to anticipate this.

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Table1. Age-standardized rates of hip fractures in females and males aged 50 yearsand over in different populations* (per 100,000 adults).

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

* * Standardised according to 1985 US whitepopulation

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