High Rates of Imminent Subsequent Fracture After Femoral Neck Fracture in the Elderly

Abstract

Background:Fragility fractures of the hip are known to be followed frequently by subsequent fragility fractures, including second hip fractures. Data on subsequent fractures are available for aggregated index femoral neck and intertrochanteric femoral fractures, grouped generically as hip fractures, but not specifically for femoral neck fractures. There is increasing recognition that a subsequent fracture often occurs early after a hip fracture in the elderly, creating an emphasis on the concept of “imminent fracture risk.” Since 2000, there have been many reports on the care gap in interventions after a fragility fracture, with concern regarding the slow uptake of appropriate systemic treatments designed to prevent a subsequent fracture in high-risk patients.Methods:As planned a priori, we performed an analysis of subsequent fractures after an index femoral neck fracture in 2 prospective clinical trials involving 2,520 patients from 90 sites on 5 continents. We recorded the incidence and time of occurrence of all secondary fragility fractures as well as the reported use of bone-protective medication in all subjects.Results:In the 24 months following the index femoral neck fracture, 226 (9.0%) of 2,520 patients sustained at least 1 subsequent fragility fracture, including 113 hip fractures (4.5%). The median interval from the index fracture to a subsequent fracture was approximately 9.0 months. Only 25.2% (634) of the 2,520 patients reported using bone-protective medications at any time during follow-up. Female patients, those with nondisplaced index fractures, and those treated with arthroplasty, were more likely to have received protective medication.Conclusions:Subsequent fractures, including second hip fractures, occurred frequently and early following an index femoral neck fracture in 2 large global cohorts. Interventions to prevent a subsequent fracture were instituted in only 1 of 4 patients, even though a focused directive was included in both study protocols.Level of Evidence:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Risk factors for subsequent fractures in hip fracture patients: a nested case-control study

“…In recent years, there has been increasing awareness and emphasis on preventing subsequent fractures [ 15 ]. Clinical guidelines emphasize identifying modifiable risk factors for subsequent fractures [ 16 – 18 ]. While risk factors for initial hip fractures are relatively well-established, our understanding of the determinants for additional fractures remains less clear.…”

The low and disproportionate utilization of antiresorptive therapy in patients with osseous metastasis

“…However, limited literature exists regarding the utilization of antiresorptive prescriptions, its risk reduction for SREs in varying primary cancers, and the existence of prescription biases in this at-risk population. Recent orthopaedic trauma and spine literature has documented low rates of antiresorptive prescriptions in patients who sustained fragility fractures [7] , [8] . Barton et al [7] retrospectively analyzed patients 50 years old or greater with new vertebral compression fractures and found only 12 % of patients initiated antiresorptive therapy within 1-year of fracture with 38 % of patients sustaining a second fragility fracture within 2-years.…”

“…Barton et al [7] retrospectively analyzed patients 50 years old or greater with new vertebral compression fractures and found only 12 % of patients initiated antiresorptive therapy within 1-year of fracture with 38 % of patients sustaining a second fragility fracture within 2-years. Bogoch et al [8] also illustrated low rates of antiresorptive therapies, with only 25 % of patients following fragility hip fractures receiving these therapies. While the significant treatment gap is well established in the osteoporosis population, the utilization of these therapies in patients with osseous metastasis is unknown.…”