Abstract Hip fracture is a trauma with serious consequences, especially in the elderly. Etiological factors should be known better than nowadays to recognize the individuals at high risk. Also, the treatment of displaced femoral neck fractures has been controversial, and the factors leading to a functional outcome are not known well. The true impact of deep infection on the outcome after hip fracture surgery has also been insufficiently examined. The thesis is based on two etiological studies. In the first study, the geometrical parameters of the upper femur and pelvis in postmenopausal women with hip fracture were (n=70) compared to age-adjusted controls (n=40). Measurements were made from position-standardized and calibrated pelvic plain x-rays. The differences between the two different types of hip fracture, femoral neck fractures (n=46) and trochanteric fractures (n=24) were also defined. High femoral neck/shaft angle (NSA), thin femoral cortices, low femoral shaft diameter (FSD) and trochanter width and the pelvic dimensions associate strongly with the hip fracture risk in postmenopausal women. Greater NSA, smallest outer pelvic diameter and acetabular width, narrower FSD and smaller femoral neck/shaft cortex ratio were associated with femoral neck fracture rather than trochanteric fracture in postmenopausal women. In the second study, lifetime factors, some bone metabolism markers and bone mineral density were analyzed from postmenopausal women (n=74; 49 with femoral neck fracture, 25 with trochanteric fracture) and age-adjusted controls (n=40). Impaired functional ability, use of loop diuretics, antidiabetic, antidepressant and neuroleptic drugs, some concurrent diseases, such as stroke, diabetes, malignancy, cardiovascular diseases, low bone mineral density of the upper femur, low serum calcium, low serum 25-hydroxyvitamin D and high serum calcitonin, seem to be related to the risk of hip fracture, while low bone mineral density and low serum calcitonin are related to the trochanteric type of fracture in postmenopausal women. The treatment of displaced femoral fractures included two prospective case-control studies, and the first of these involved a comparison (357 matched pairs) of patients with osteosynthesis (OS) with two pins in Lund and patients with uncemented hemiarthroplasty (HA) in Oulu. The patients treated with OS had 4 months after fracture better ambulatory capacity, used walking aids less often and had less pain than the patients treated with HA. The other comparison (84 matched pairs) was made between OS with three screws and uncemented HA, and it revealed no significant differences between HA and OS in the short-term functional outcome. Both studies revealed a higher re-operation rate in OS patients than uncemented HA patients. The case-control study with 29 matched pairs showed that deep infection after a hip fracture operation impairs the short-term functional outcome and slightly increases mortality, with an attributable mortality rate of 10 %. In conclusion, this thesis suggests that the geometry of the upper femur and pelvis, the aforesaid lifetime factors, the aforesaid metabolism markers and bone mineral density are associated with the etiopathology and type of hip fracture in postmenopausal women. The short-term functional outcome was better in OS patients treated with two pins compared to uncemented HA, but the higher re-operation rate should be considered among the OS patients. Deep infection is a serious complication of hip fracture surgery, which impairs function and increases mortality.

Hip fracture is the leading cause of acute orthopaedic hospital admission amongst the elderly, with around a third of patients not surviving one-year post-fracture. Current risk assessment tools ignore cortical bone thinning, a focal structural defect characterizing hip fragility. Cortical thickness can be measured using computed tomography, but this is expensive and involves a significant radiation dose. Dual-energy X-ray absorptiometry (DXA) is the preferred imaging modality for assessing fracture risk, and is used routinely in clinical practice. This thesis proposes two novel methods which measure the cortical thickness of the proximal femur from multi-view DXA scans. First, a data-driven algorithm is designed, implemented and evaluated. It relies on a femoral B-spline template which can be deformed to fit an individual?s scans. In a series of experiments on the trochanteric regions of 120 proximal femurs, the algorithm?s performance limits were established using twenty views in the range 0? ? 171?: estimation errors were 0.00 ? 0.50 mm. In a clinically viable protocol using four views in the range ?20? to 40?, measurement errors were ?0.05 ? 0.54 mm. The second algorithm accomplishes the same task by deforming statistical shape and thickness models, both trained using Principal Component Analysis (PCA). Three training cohorts are used to investigate (a) the estimation efficacy as a function of the diversity in the training set and (b) the possibility of improving performance by building tailored models for different populations. In a series of cross-validation experiments involving 120 femurs, minimum estimation errors were 0.00 ? 0.59 mm and ?0.01 ? 0.61 mm for the twenty- and four-view experiments respectively, when fitting the tailored models. Statistical significance tests reveal that the template algorithm is more precise than the statistical, and that both are superior to a blind estimator which naively assumes the population mean, but only in regions of thicker cortex. It is concluded that cortical thickness measured from DXA is unlikely to assist fracture prediction in the femoral neck and trochanters, but might have applicability in the sub-trochanteric region.

Purpose: Recent findings suggest a role for heart failure in the etiology of osteoporotic fractures, yet the temporal sequence of occurrence of the 2 conditions needs clarification. Methods: Using the Rochester Epidemiology Project, the authors conducted a 2-phase study: a case-control study compared osteoporotic fracture history among Olmsted County, Minnesota, residents newly diagnosed with heart failure in 1979-2002 with age- and sex-matched community controls without heart failure (961 pairs; mean age 76 years; 54% women). Both groups were then followed to July 2009 to evaluate their subsequent fracture risk in a cohort study. Results: Prior fractures were more frequent in heart failure cases than controls (23.1% vs. 18.8%, P = .02). The adjusted odds ratio (OR) for heart failure associated with prior fracture was 1.39 (95% confidence interval [CI], 1.07-1.81), mainly driven by hip fractures (OR 1.82; 95% CI, 1.25-2.66) with little or no association with other fractures. Over a mean follow-up of 7.5 years, 444 individuals developed subsequent osteoporotic fractures. The adjusted fracture risk was marginally elevated in heart failure patients compared with controls (hazard ratio [HR] 1.32; 95% CI, 0.98-1.79), again largely attributable to hip fractures (HR 1.58; 95% CI, 1.03-2.41). Conclusions: In this community, the association with fracture risk was about as strong before as after the diagnosis of heart failure and was nearly entirely attributable to hip fractures. Additional work is needed to identify common underlying mechanisms for heart failure and hip fracture, which may define prevention opportunities.

Background: Bone and mineral metabolism disorders are common among end-stage renal disease (ESRD) patients, which could lead to hip fracture. It is unclear whether the hip fracture risk is different among patients on hemodialysis (HD) versus peritoneal dialysis (PD). This meta-analysis was conducted to evaluate the hip fracture risk in ESRD patients on HD, when compared to PD. Methods: A literature review was conducted in EMBASE, MEDLINE, and Cochrane databases through January 31, 2018 to identify studies that appraised the rate or risk of hip fracture among patients on HD, when compared to PD. Effect estimates from the individual studies were derived and consolidated utilizing random-effect, generic inverse variance approach of DerSimonian and Laird. Results: Five cohort studies with 1 276 677 ESRD patients were enrolled. HD status was associated with a significantly higher risk of hip fracture with the pooled odds ratio (OR) of 1.61 (95% confidence interval [CI] 1.50-1.73, I2 = 10.0%), compared with PD. When the analysis was limited to studies with confounder-adjusted analysis, the pooled OR of hip fracture among HD patients was 1.57 (95% CI 1.43-1.72, I2 = 13.6%). Funnel plots and Egger's regression test demonstrated no significant publication bias in our meta-analysis. Conclusions: Among ESRD patients, HD status is associated with a 61% higher risk of hip fracture compared to PD.

Hip fracture in older adults may be the sentinel event leading to functional decline, long-term disability, and death. For the substantial number of older persons who fracture a hip each year, the chances of full functional recovery remains relatively low. The purpose of this study was to examine the differences between older persons with hip fracture who recover fully and those individuals who do not fully recover. A chronic disease trajectory framework guided the theoretical design of the research. Data were collected from the medical records of 102 persons aged 60 years and older who sustained a proximal hip fracture from 1993 to 1998 at a medical center in North Carolina. Data included personal characteristics, prefracture health status, hospital factors, rehabilitation features, and functional outcomes. The analysis consisted of a two-step hierarchical logistic regression model with the control variables of age, prefracture ambulation status, and prefracture cognitive status entered first and the variables of type of therapy program, frequency of therapy, number of therapy provider organizations, and location of therapy at 4 weeks entered second. Significance of the final model was observed, Chi-Square(7, n = 99)=43.55, p < .05. Significant individual predictors (p < .05) in the model were prefracture ambulation status (43.56 odds ratio) and cognitive status (6.44 odds ratio). Post-hoc analysis of the cases revealed a substantial lack of stability in ambulation status from three months post-fracture to the six-month and one-year follow-up. Findings support other research studies that indicate prefracture personal characteristics of older persons who fracture a hip are the most influential factors in predicting successful recovery. Linkage of the findings to the chronic disease trajectory model suggests that intervention efforts should focus on prevention, health promotion, and policies that extend the ability of health care providers to assist older persons with hip fracture in managing their conditions. / Ph. D.

Protein is an important component of bone, but the role of dietary protein intake in osteoporosis remains controversial. The Utah picture-sort food frequency questionnaire was found to produce a useful estimation of usual dietary intake in the elderly. This method of dietary assessment was used in a population-based case-control study to examine the relationship between protein intake and risk of osteoporotic hip fracture in elderly Utah residents. Analyses of risk of hip fracture across increasing quartiles of protein intake were stratified by age-group. Higher protein intake was associated with a reduced risk of hip fracture in men and women aged 50-69 years but did not appear to increase or decrease risk of hip fracture in those aged 70-89 years. The relationship appeared to be modified by age. Modification of protein intake late in life may be a useful means to prevent hip fractures in the elderly.

Hip fractures are common injuries with devastating consequences, including high rates of morbidity and mortality. The purpose of my thesis was to lay the foundation for further research which can fully explore: i) the epidemiology of morbidity and mortality following hip fracture; ii) risk factors for poor outcomes following hip fracture; iii) causes and pathways to mortality following hip fracture; iv) secondary prevention of morbidity and mortality following hip fracture; and v) potential interventions to improve outcomes following hip fracture. To this end, I will first detail the design, execution, results, and ‘lessons learned’ of a prospective observational pilot cohort study that recruited 100 consecutive patients aged ≥18 years presenting with a hip fracture to the Juravinski Hospital and Cancer Centre of the Hamilton Health Sciences. The primary aim of this pilot study was to assess the feasibility of a larger prospective international cohort study. Second, I will present a systematic review and meta-analysis of a promising intervention that consisted of multi-disciplinary (specifically geriatrician-led) co-management of hip fracture patients. This intervention has previously been shown to reduce mortality and length of stay following hip fracture. The meta-analysis presented will determine the effectiveness of this intervention in reducing the incidence, duration, and severity of delirium—a common condition following hip fracture. / Thesis / Master of Science (MSc)

Hip fractures in older adults have severe effects on patients’ morbidity as well as mortality, so it is crucial to avoid this injury through the early identification of patients at high risk. Currently, the diagnosis of osteoporosis and consequently hip fracture risk is done through the measurement of bone mineral density by a dual-energy X-ray absorptiometry (DXA) scan. However, studies show that this method is not accurate enough, and a high percentage of patients who sustain a hip fracture had non-osteoporotic DXA scans less than a year before the incidence. In this research, to enhance the hip fracture risk prediction, the effect of a femur’s geometry and bone mineral density distribution was considered in the hip fracture risk estimation. This was done through 2D and 3D statistical shape and appearance modeling of the proximal femur using standard clinical DXA scans. To assess the proposed techniques, destructive mechanical tests were performed on 16 isolated cadaveric femurs. Also, through collaboration with the Canadian Osteoporosis Study (CaMos), the proposed statistical techniques to predict the hip fracture risk were evaluated in a clinical population as well. The results of this study showed that new techniques can enhance hip fracture risk estimation; in the clinical study, 2D and 3D statistical modeling were able to improve identifying patients at high risk by 40% and 44% over the clinical standard method. Also, the percentage of correct predictions using 2D statistical models did not differ significantly from the 3D predictions. Therefore, by applying these techniques in clinical practice it could be possible to identify patients at high risk of sustaining a hip fracture more accurately and eventually reduce the incidence of hip fractures and the pain and social and economic burden that comes with it. / Thesis / Doctor of Philosophy (PhD) / Diagnosis of osteoporosis and consequently hip fracture risk is based on the measurement of bone mineral density in clinical imaging called DXA scanning. However, studies have shown that this method is not sufficient in identifying all patients at high risk of sustaining a hip fracture. The purpose of this work was to incorporate the geometry and bone mineral density distribution of the proximal femur in hip fracture risk prediction through image processing of DXA scans. Two algorithms of 2D and 3D statistical shape and appearance modeling were implemented and evaluated in a cadaveric study (comparing the predicted fracture load to measured ones) as well as a clinical study (comparing the fracture predictions to the fracture history of patients). The results indicated that new techniques can enhance hip fracture risk estimation compared to the clinical standard method, and hence the devastating injury can be prevented through applying protective measures.

The overall aim of this thesis was to evaluate methods for urinary catheter handling in patients undergoing hip surgery. The intention was to gain knowledge in order to provide optimal and cost- effective care regarding urinary catheterisation in this group of patients. In Study I , 45 of the 86 catheterised patients (52%) contracted nosocomial urinary tract infections (UTIs). Diabetes was a risk factor for developing UTI, and cloxacillin as a perioperative antibiotic prophylaxis seemed to offer a certain protection. Study II was a randomised controlled trial on the effect of clamping (n = 55) or not (n = 58) of the indwelling urinary catheter before removal. No significant differences were found between the groups with respect to time to normal bladder function, need for recatheterisation, or length of hospital stay. Study III was a randomised controlled trial among patients with hip fracture and hip arthroplasty, in which the patients were randomised to intermittent (n = 85) or indwelling (n = 85) urinary catheterisation. No significant differences in nosocomial UTIs (9% vs. 12%) or cost-effectiveness were shown. The patients in the intermittent group regained normal bladder function significantly sooner after surgery. Fourteen percent of the patients in the intermittent group did not need any catheterisation. In Study IV , 30 patients were interviewed about their experiences of bladder emptying and urinary catheterisation. The patients’ views were described through the main category ‘An issue but of varying impact’. Both bladder emptying through micturition and bladder emptying through catheterisation were described as convenient, but also as uncomfortable and an intrusion on dignity. The patients were aware of risks and complications of urinary catheterisation. In conclusion, this thesis indicates that UTI is common in hip surgery patients. Clamping of indwelling catheters seems not necessary. There is no preference for either intermittent or indwelling urinary catheterisation according to the results of this thesis, either for the development of nosocomial UTI or, for cost-effectiveness, or from the patient perspective. Nurses should be aware that catheterisation might make the patients feel exposed, and it is essential that their practice reflect the best available evidence.

Bakgrund: Medelåldern för att drabbas av höftfraktur är 80 år och bakomliggande orsaker är falltendens och benskörhet. Majoriteten av dem som drabbas av höftfraktur är kvinnor. Att drabbas av höftfraktur kan innebära ett stort lidande, det är ofta en smärtsam upplevelse, både vid själva skadetillfället men även under vårdtiden. Syfte: Att beskriva patienters upplevelser av vården vid höftfraktur. Metod: Denna studie genomfördes som en litteraturöversikt, där databaserna Cinahl, Psycinfo, PubMed och Web of Science användes vid artikelsökningen. Resultat: Resultatet baserades på tio artiklar, av kvalitativ och kvantitativ design. Patienternas upplevelser av vården vid höftfraktur resulterade i tre kategorier: kommunikation och information, bemötande och trygghet samt smärta och smärtlindring. Patienterna ville vara delaktiga och få löpande information om vad som hände och vad som skulle ske gällande deras vård. Trygghet var en känsla som tillkom av beröring från vårdpersonalen och uppskattades då patienterna upplevde sig som utsatta. Smärtlindringen var viktig för att patienterna skulle känna välbefinnande och inte ha ont. Konklusion: Kommunikation är den röda tråden genom resultatets alla delar. Patienternas upplevelser av information, trygghet, bemötande, smärta och smärtlindring påverkas alla av hur väl kommunikationen mellan dem och vårdpersonalen har fungerat. Det är därför viktigt att sjuksköterskor försöker identifiera varje patients individuella förutsättningar och behov för att ha möjlighet att anpassa information, kommunikation och egenvård så att varje patients behov tillgodoses. / Background: The average age of suffering a hip fracture is 80 years, and the causes are falls tendency and osteoporosis. The majority of those who suffer from a hip fracture are female. To suffer a hip fracture could mean great suffering, it is often very painful, both at the time of the injury, but also during the hospital stay. Aim: To describe patients' experiences of care at hip fracture. Method: This study was conducted as a literature review, in which ten articles were included. The databases used in this study was Cinahl, Psycinfo, PubMed and Web of Science. Results: The results were based on ten articles, which were of qualitative and quantitative methods. The patients' experiences of care at hip fracture resulted in three categories: communication and information, treatment and safety and pain and pain relief. The patients wanted to be involved and receive ongoing information regarding their care. When patients experienced themselves as vulnerable the touch from the nursing staff created a sense of security. Pain relief was important for patients to feel the well-being and not have pain. Conclusion: Patients' experiences of information, security, treatment, pain and pain relief are all affected by communication. It is important for nurses to identify each patient's individual circumstances and needs in order to be able to adapt the information, communication and self-care to meet each patient's needs.