|Year : 2019 | Volume
| Issue : 3 | Page : 282-288
Predictors and outcome of fragility hip fracture: A prospective study from North India
Deba Prasad Dhibar1, Yashpal Gogate2, Sameer Aggarwal3, Sudhir Garg4, Anil Bhansali2, Sanjay Kumar Bhadada2
1 Department of Internal Medicine, PGIMER, Chandigarh, India
2 Department of Endocrinology, PGIMER, Chandigarh, India
3 Department of Orthopaedics, PGIMER, Chandigarh, India
4 Department of Orthopaedics, GMCH, Chandigarh, India
|Date of Web Publication||30-Jul-2019|
Sanjay Kumar Bhadada
Department of Endocrinology, F-Block, Nehru Hospital, PGIMER, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Fragility hip fracture is a useful surrogate marker of the burden of osteoporosis. With improving life expectancy and progressive ageing of population, the global burden of osteoporotic fracture is increasing. Despite this, there is paucity of data regarding epidemiology, predictors, and outcomes of fragility hip fractures in the Indian population. Methods: In this multicenter, prospective observational study, 264 patients of fragility hip fracture were followed up for 12 months. Results: Men (46.2%) and women (53.8%) had a nearly equal distribution of fragility hip fracture. Mean (±SD) age of study population was 65.9 ± 12.6 years and men had earlier age (64.7 ± 12.6 years) of fracture as compared to women (66.9 ± 12.6 years). Out of these, 89.7% patients had osteoporosis, 7.6% had osteopenia, and 2.7% patients had normal bone mineral density (BMD). Fractures predominantly occurred inside the home (229, 86.7%) as compared to outside (35, 13.3%). Female gender, hypertension, diabetes, anemia, smoking, and alcohol were associated with lower BMD, but not a predictor of morbidity. Aging (P = 0.000), osteoporosis (P = 0.012), and diabetes (P = 0.008) were predictors of increased mortality. A total of 243 (92%) patients underwent surgery with a mean hospital stay of 13.5 ± 2.9 days and 34 (12.9%) patients died. Maximum death (73.5%) occurred in first 3 months and the commonest cause of death was cardiovascular (44.1%) related. Conclusion: The majority of fragility hip fractures occurred inside the home. Distribution of fractures in either gender is comparable. Aging, osteoporosis, and diabetes are predictors of poor outcome. We recommend development of newer strategies that target male as well as female patients with osteoporosis with particular attention to prevent in-house falls and fractures.
Keywords: Bone mineral density, fragility hip fracture, morbidity, mortality, osteoporosis
|How to cite this article:|
Dhibar DP, Gogate Y, Aggarwal S, Garg S, Bhansali A, Bhadada SK. Predictors and outcome of fragility hip fracture: A prospective study from North India. Indian J Endocr Metab 2019;23:282-8
|How to cite this URL:|
Dhibar DP, Gogate Y, Aggarwal S, Garg S, Bhansali A, Bhadada SK. Predictors and outcome of fragility hip fracture: A prospective study from North India. Indian J Endocr Metab [serial online] 2019 [cited 2019 Aug 17];23:282-8. Available from: http://www.ijem.in/text.asp?2019/23/3/282/263692
| Introduction|| |
Osteoporosis is a rapidly growing major public health problem of the aging population. Spine fracture is the most common type of osteoporotic fracture, but osteoporotic hip fracture is the major cause of morbidity and mortality. About 30% of people with hip fracture die in the following year and rest experience significant functional loss. Based on 2001 census, approximately 163 million Indians were above 50 years of age. This number is expected to increase to 230 million by 2015, affecting around 25 million people with osteoporosis. Fragility hip fracture is useful surrogate marker for the burden of osteoporosis. It accounts for <20% of all osteoporotic fractures but is responsible for high morbidity, mortality, and healthcare-related expenditures. In addition, it also increases the risk of future fracture, increasing the morbidity and mortality further., Mortality after hip fracture is significantly high, 11–23% at 6 months and 22–29% at 1 year. Despite the huge burden of osteoporosis, there is paucity of data regarding epidemiology, risk factors, and outcome of fragility hip fracture in the Indian population. In this study, we analyzed fragility hip fractures in three parts. First, the prefracture part was regarding epidemiology, risk factors, and comorbidities. Second, the fracture part was regarding type of fracture, associated fractures, and management. Finally, the postfracture part was regarding morbidity and mortality outcomes.
| Materials and Methods|| |
Study design and population: This was multicenter, prospective, observational time bound study conducted during the year of 2011-2012. A total of 264 patients were recruited consecutively from hospitals of Chandigarh, north India for 1 year and subsequently were followed up for another 12 months. All patients were ≥18 years of age, irrespective of gender and had radiologically proven fragility fracture of hip, involving either neck of femur (NOF), intertrochanteric or subtrochanteric region. Patients with nonfragility fracture were excluded from the study.
Methods: Detail history was taken regarding, age, gender, trauma, previous fracture, risk factors, and comorbidities. Clinically, a fragility fracture was defined as a fracture that occurred as results of minimal trauma, such as fall from a standing height or less, or without identifiable trauma. Details of the fractures, treatment received, complications, and duration of hospital stay were also documented. Patients were followed up at 3, 6, and 12 months for morbidity and mortality. The patient's activity was assessed using activity score and physical endurance testing using global physical activity questionnaire (G-PAQ) score. Patients were also quantified into various probabilities based on FRAX tool. A baseline complete blood count, renal and liver function test, serum calcium, phosphate, and alkaline phosphatase were done in all the patients. Serum 25(OH) vitamin D (vitamin D) and intact parathyroid hormone (iPTH) were also measured at baseline by electroechemeluminescence immune assay (ECLIA). Anemia was defined as hemoglobin (Hb) of <13 g/dl for male, <12 g/dl for female, and vitamin D of <20 ng/ml was considered as deficiency. All patients underwent dual-energy X-ray absorptiometry (DXA) scan at the nonfracture side of hip or lumbar spine. Osteoporosis was defined as T-score of ≤–2.5 in the lumbar spine, NOF, or total hip, as per WHO criteria. T-score of -1.0 to -2.4 was defined as osteopenia and a T score >-1.0 was defined as normal. For premenopausal women and young men BMD Z-score was used to define osteoporosis.
The data were expressed as mean (±SD) unless otherwise stated. Data were analyzed using SPSS-20 software package. Independent t-test was used to compare the difference of mean where applicable. Mann–Whitney U test was used to compare the variables that were not normally distributed. Correlation analysis was done by Pearson's correlation for parametric data and Spearman's correlation for nonparametric data. A P value of < 0.05 was considered significant. Regression analysis with curve estimation was done to find out the relationship between explanatory variable on a response variable.
| Results|| |
Baseline data of the study population
: Mean age of study population was 65.9 ± 12.6 years, ranging from 32 to 90 years. Maximum number (81) of patients was from 61 to 70 years age-group (30.7%). Number of patients from 31-40 years, 41-50, 51-60, 71-80, and 81-90 years age-group were 11 (4.2%), 22 (8.3%), 59 (22.3%), 56 (21.2%), and 35 (13.3%), respectively. The mean age for men and women was 64.7 ± 12.6 and 66.9 ± 12.6 years respectively (P = 0.166). Thirteen patients had previous history of fragility hip fracture. Taking this into account, mean age of presentation of first hip fracture was 65.5 ± 12.9 years. Age did not influence the morbidity (P = 0.061) but was an independent predictor of mortality (P = 0.000) in present study.
Most commonly associated comorbidities were anemia (81.1%), followed by hypertension (27.3%) and type 2 diabetes mellitus (T2DM) (25.4%) [Figure 1].
Mean (±SD) serum calcium, phosphate, and alkaline phosphatase levels were 8.9 ± 0.7, 3.7 ± 0.9 mg/dl and 142 ± 92.2 IU/L respectively [Table 1]. Mean (±SD) serum vitamin D and iPTH level were 8.4 ± 5.0 ng/ml and 128.5 ± 340.5 pg/ml, respectively [Table 1]. Out of 264 patients, 257 (97%) had vitamin D deficiency and 150 (56.8%) patients had secondary hyperparathyroidism, but there was no significant difference in calcium and phosphate level.
Bone mineral density: DXA at NOF was done in 224 patients which showed 201 (89.7%) patients had osteoporosis, 17 (7.6%) had osteopenia, and 6 (2.7%) patients had normal bone mineral density (BMD). DXA at lumbar spine was done in 226 patients which showed, 183 (81%) patients had osteoporosis, 25 (11.1%) had osteopenia, and 18 (7.9%) patients had normal BMD. The patients with osteoporosis at spine (P = 0.003) or hip (P = 0.012) had significantly increased mortality.
Risk factors and comorbidities
- 1. Gender: Out of 264 patients, 122 (46.2%) were men. Women had significantly lower BMD as compared to men [Table 1]. FRAX probability for major osteoporotic fracture was significantly (P < 0.00001) higher in women (17.7 ± 5.8) as compared to men (9.5 ± 3.6). FRAX probability for hip fracture was also significantly higher (P = 0.00) in women (9.0 ± 4.1) as compared to men (5.7 ± 3.5). Among the women 94% were postmenopausal with mean age of menopause was 49.1 ± 6.6 years. BMD at both spine and NOF were significantly lower in postmenopausal women [Table 2], but gender was not a predictor of morbidity (P = 0.112) and mortality (P = 0.754).
- 2. Previous fragility fracture: Out of 264 patients, 45 (18.6%) had previous history of fragility fracture. Among this commonest was fracture of hip in 13 (4.9%), followed by Colles in 10 (3.8%), tibial in 7 (2.6%), vertebral in 6 (2.2%), and proximal humerus fracture in 5 (1.9%) patients. The mean duration of subsequent fracture was 5.5 ± 3.3 years. The BMD [Table 2], morbidity (P = 0.243) and mortality (P = 0.291) were not significantly different in patients with or without previous fragility fracture.
- 3. Hypertension: According to our study, BMD at spine and NOF were significantly lower in patients with hypertension as compared to those without hypertension [Table 2]. But hypertension was not associated with poor morbidity (P = 0.777) or mortality (P = 0.884).
- 4. Diabetes: Patients with diabetes had significantly lower BMD at NOF [Table 2]. After adjustment for confounding factors, gender, postmenopausal status, hypertension, smoking, alcohol, and GPAQ activity, the BMD was not significantly different in patients with or without diabetes (P = 0.459). As per our study diabetes was not associated with poor morbidity (P = 0.142) but it was an independent predictor of mortality (P = 0.008).
- 5. Cardiorespiratory illness: The presence of cardiac illness was associated with poor morbidity (P = 0.021) but not with increased mortality (P = 0.747). BMD was not significantly different in patients with or without respiratory illness [Table 2]. But the presence of respiratory illness associated with poor morbidity (P = 0.004) as well as increased mortality (P = 0.004); this association remained significant even after adjustment for confounding factors.
- 6. Rheumatoid arthritis (RA): Patients with RA had significantly lower BMD [Table 2], but this was not significant after adjustment for confounding factors. According to our study, RA was not associated with increased morbidity (P = 0.083) or mortality (P = 0.366).
- 7. Smoking and alcohol: Out of 264 patients, 47 (17.8%) were smoker and 31 (11.7%) were alcoholic (≥3 drinks/day). Smokers and alcohol consumers had lower BMD as compared to nonsmokers and nonalcoholic, respectively, but difference was not statistically significant [Table 2]. Smoking and alcohol was not associated with poor morbidity (P = 0.292, P = 0.223) or mortality (P = 0.167, P = 0.621).
- 8. Sun exposure: 'Exposure of both hand and face to direct sunlight without any clothing, for 15–20 minutes daily for 5 days a week' was considered as adequate sunlight exposure. Out of 264 patients, 46 (17.4%) had history of adequate sun exposure. Mean vitamin D level was not significantly (P = 0.384) different in patients with (7.4 ± 2.8 ng/ml) or without (8.6 ± 5.4 ng/ml) adequate sun exposure. Patients with adequate sun exposure had significantly higher BMD [Table 2] and higher GPAQ activity (P = 0.00), but was not associated with morbidity (P = 0.627) or mortality (P = 0.558).
- 9. Anemia: Mean Hb was 10.6 ± 1.7 g/dl. Patients with anemia had lower BMD as compared to those without anemia but not statistically significant [Table 2]. As per our study, anemia was not associated with poor morbidity (P = 0.240) or mortality (P = 0.670).
- 10. Renal dysfunction: Out of 264 patients 29 (11.0%) patients had renal dysfunction with baseline serum creatinine of 1.5 mg/dL or more. Patients with renal dysfunction had lower BMD at NOF (0.463 ± 0.339) and spine (0.659 ± 0.338) as compared to patients without renal dysfunction at NOF (0.495 ± 0.237) as well as spine (0.708 ± 0.343); however, it could not reach to statistical significance [Table 2].
Place and cause of fracture: All 264 patients, had history of falls, which predominantly occurred inside the home (229, 86.7%) as compared to outside home (35, 13.3%). Significantly large number of patients (77) had fall from bed (29.2%), followed by in bathroom (56, 21.2%) and garden or courtyard (41, 15.5%). Rest of the patients had history fall at road (28, 10.6%), from stairs (27, 10.2%), at drawing room (12, 4.5%), and at other places (23, 8.8%). The most frequent cause of fall was wet floor (86, 32.6%) followed by poor light (40, 15.2%). Other causes of fall were imbalance (20, 7.6%) and obstruction (19, 7.2%). Patients who had history of fall in and around the home had significantly (P = 0.001 and P = 0.002) lower BMD at spine (0.798 ± 0.186) and NOF (0.563 ± 0.120) as compared to those had fall outside the home (0.916 ± 0.204 and 0.652 ± 0.153). The mean duration (hour ± SD) taken for first medical consultation was also significantly (P = 0.000) higher for those, who sustained fracture in and around home (25.4 ± 49.1) as compared to those had fall outside the home (2.75 ± 4.04). The patients who had sustained fracture outside the home also had higher GPAQ activity score (P = 0.000). But the place of fall was not a predictor of poor morbidity (P = 0.663) or increased mortality (P = 0.596). Out of 264 fragility hip fractures, 140 (53%) were intertrochanteric, followed by 108 (41%) NOF and 16 (6%) were subtrochanteric fracture. Intertrochanteric fracture was associated with poor morbidity as compared to fracture NOF (P = 0.002), but the type of fracture was not a predictor of increased mortality (P = 0.150). Other associated fractures were noted in 11 (4.2%) patients, but it was not predictor of poor morbidity (P = 0.112) or mortality (P = 0.072).
Use of drugs: The patients, who were using β blocker, had significantly lower BMD [Table 3]. The patients who were receiving steroid, thiazide, and statin had lower BMD but statistically not significant [Table 3]. As per our study, use of steroid was not associated with poor morbidity (P = 0.477) or increased mortality (P = 0.266). Stain, thiazide, and β blocker use was also not associated with poor morbidity or mortality.
Treatment and outcome: Out of 264 patients with fragility hip fracture, 243 (92%) underwent surgical management and 21 (8%) received conservative management. All patients received 1000 mg of calcium per day and vitamin D of 600000 U (cholecalciferol) weekly during the 1 year follow-up. The mean duration of hospital stay was 13.5 ± 2.9 days. According to our study, the patients who received conservative management did not have poor morbidity (P = 0.077) or increased mortality (P = 0.141) as compared to those who underwent surgery.
Out of 264 patients, 204, 180, and 158 patients could be followed up, at the end of 3rd, 6th, and 12th months, respectively [Table 4]. Total 34 (21.5%) patients died during the course of 1 year follow-up. Maximum number (25) of deaths occurred in first 3 months (73.5%), followed by 5 (14.7%) at 6th month and 4 (11.8%) at the end of 12th month. At the end of 3rd month, the commonest cause of death was cardiovascular 15 (44.1%), followed by sepsis secondary to hospital acquired pneumonia (6, 17.6%) and urinary tract infection (4, 11.8%). Cause of death at the end of 6th month was cardiovascular (4, 11.8%), followed by sepsis related to implant (1, 2.9%). The rest of the four (11.8%) patients died at the end of 12 months from cardiovascular illness.
| Discussion|| |
We have showed majority of fragility hip fractures occurred inside the home. Men and women have comparable risk of fragility hip fracture. More than 90% of patients had vitamin D deficiency. Aging, osteoporosis, and diabetes are predictors of increased mortality.
Population: In American and European populations, hip fracture is twice more prevalent in women as compared to men for any age group. In our study, men (46.2%) and women (53.8%) had a near equal distribution of fragility hip fracture. One possible reason could be the difference of life expectancy. In India, the life expectancy at birth is 61.8 years for men and 63.5 years for women. However in America, the life expectancy at birth is 75.2 years for men and 80.4 years for women. We also observed that the FRAX probability for both major osteoporotic fracture and hip fracture was significantly lower in men as compared to women. Previous study has shown male gender as predictor of poor outcome. However, according to our study morbidity and mortality was not significantly different in men and women. This could be because of men had significantly better BMD as compared to women.
In our study, the mean age for fragility fracture was 65.9 ± 12.6 years, which is much lower than the mean age (80.6 years) for hip fracture worldwide. Even Indians settled in Singapore had hip fracture at an earlier age. Possible explanation may be genetic and dietary differences. Another important finding was earlier age (p 0.166) of fragility hip fracture in men (64.7 ± 12.6 years) as compared to women (66.9 ± 12.6 years). Advanced age has also been shown as predictor of poor morbidity as well as mortality. According to our study, age was not associated with poor morbidity but associated with increased mortality. These further emphasize on the need for targeting male osteoporosis and India specific osteoporosis prevention guidelines.
Comorbidities and risk factors: History of previous fragility fracture is an independent risk factor for subsequent fracture, although its relation with morbidity and mortality outcome has not been established. In our study, patients with previous fragility fracture had higher BMD as compared to those without previous fracture, but statistically not significant. This could be because of increased calcium, vitamin D, and antiosteoporotic medicine intake previously. According to our study, previous history of fragility fracture was not associated with poor morbidity or increased mortality.
The role of hypertension as a risk factor for hip fracture is controversial. In our study, BMD was significantly lower in patients with hypertension as compared to those without hypertension. However, serum level of creatinine, calcium, vitamin D, and iPTH were not significantly different in patients with or without hypertension. Even after adjusting for confounding factors, the BMD was significantly lower in patients with hypertension (P = 0.020). This suggests some direct effect of hypertension on bone health, which needs further study.
There is substantial evidence that patients with T2DM have increased risk for hip fracture., A recent meta-analysis reported a relative risk of 1.7 for hip fracture in patients with T2DM. Surprisingly, BMD is generally higher in patients with T2DM. However, in our study, patients with T2DM had lower BMD, which is significant only at NOF (P = 0.021), although after adjusting for confounding factors, it was not significant (P = 0.459). Serum level of creatinine, calcium, vitamin D, and iPTH were also not significantly different in patients with or without T2DM. In our study, diabetes was not a predictor of poor morbidity. Although statistically not significant, the duration of hospital stay was more in individuals with diabetes as compared to nondiabetic and three of them had implant failure. As reported in previous studies, our study also showed association of diabetes with increased mortality (P = 0.008), even after adjustment for confounding factors.
Like previous study, in our study, respiratory illness was also associated with poor morbidity and increased mortality, even after adjustment for confounding factors. Cardiac disease has been shown to be an independent predictor of poor outcome. In our study, it was associated with poor morbidity but not with increased mortality.
Study results on effect of RA on BMD are conflicting.,, In our study, patients with RA had significant lower BMD as compared to those without RA. However, this was not significant after adjustment with confounding factors (P = 0.262, P = 0.093). RA was also not associated with poor morbidity or mortality. But with the current small number of patients evaluated in this study and lack of evaluation of all the confounding variables, such association is questionable. Further study with larger sample size is required for better evaluation of the association of RA and bone health.
Smoking and alcohol are associated with lower BMD and increased risk for fracture., According to our study, smokers and alcohol consumers had lower BMD, but statistically not significant and these were not associated with poor morbidity or mortality.
In previous studies anemia has been found to be predictor of increased mortality. But in our study anemia was not associated with poor morbidity or increased mortality. But the high prevalence of anemia is this study cohort limits the replication ability of the results to the general population as the anemia is a marker of poor general health which is an independent predictor of falls, fractures, and poor bone health.
Renal dysfunction is also associated with increased incidence of osteoporosis. According to our study, patients with renal dysfunction had lower BMD both at NOF and spine as compared to the patients without renal dysfunction, but could not achieve statistical significance probably due to small sample size.
Vitamin D deficiency is considered as risk factors for fragility hip fracture in elderly., In our study, 97.3% patients had vitamin D deficiency. 'Exposure of both hand and face to direct sunlight without any clothing, for 15–20 minutes daily for 5 days a week' was considered as adequate sunlight exposure. In our study, patients with adequate sun exposure had significantly higher BMD but inadequate sun exposure or vitamin D deficiency was not associated with poor morbidity or mortality.
Study results on effect of beta-blocker on BMD are conflicting. Low serum osteocalcin level has been demonstrated in patients receiving beta-blocker. In our study, BMD was significantly lower in beta-blocker users but not significant after adjusting for confounding factors. Thiazide diuretics have been found to protective to fracture, by their direct effect on calcium metabolism leading to improve BMD. But we did not find any significant difference of BMD in thiazide users and nonusers. Numerous studies have shown that steroid use increases the risk of fracture. In our study, steroid user had insignificant lower BMD and was not associated with poor morbidity or mortality. Most of the studies have shown that use of statins associated with modest increase in BMD. But in our study statins user had insignificant lower BMD. With small subset of patients, association of the use of these drugs with BMD or fragility fracture cannot be established.
Fracture and outcome: Intertrochanteric fracture is associated with poor outcomes and is also an independent predictor of mortality. In our study, intertrochanteric fracture was associated with poor morbidity as compared to fracture NOF, but the type fracture was not a predictor of mortality. Surgical management is now established modality of treatment for hip fracture. In our study, patients who opted for conservative therapy did not have poor morbidity or increased mortality, suggesting that therapy is not a predictor for morbidity and mortality.
Those who sustained fracture outside the home were commonly male, had significantly better BMD, higher GPAQ activity scores, and earlier medical consultation. However, the place of fracture was not a predictor of poor morbidity or mortality. Bedroom (29.2%) and the bathroom (21.2%) were the commonest place for fracture at home. The leading cause fracture was wet floor (32.6%) and poor lighting (15.2%), both of which are preventable.
In our study, mortality rate was 21.5%, which is comparable with other studies, 11–23% at 6 months and 22–29% at 12 months from injury. But the majority of mortality (25 out of 34) was occurred at the end of 3rd month. As with most other studies,, the commonest cause of mortality in our study was cardiovascular related, followed by respiratory infection.
Limitation: The sample size was small, we could follow-up patients for 12 months only and there was around 40% drop out at the end of 12 months. We recommend further study with greater sample size and longer follow-up for better evaluation of epidemiology and outcome of fragility hip fractures in this part of the world. The high prevalence of anemia is this study cohort limits the replication ability of the results to the general population. Anemia is a marker of poor general health which is an independent predictor of falls, fractures, and poor bone health.
| Conclusion|| |
Majority of fragility hip fractures occurred inside the home. Distribution of fracture in either gender is comparable. Aging, osteoporosis, and diabetes are predictors of increased mortality.
The epidemiology, risk factors, and outcome of fragility hip fracture in this Indian population were significantly different from European and American population. There is urgent need for formation of India specific osteoporosis prevention guideline. We recommend development of newer strategies that target male as well as female patients with osteoporosis with particular attention to prevent in-house falls and fragility fractures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]