Hip fracture trials have used a wide range of patient-reported outcomes (PRO) suggesting a lack of consensus among clinicians on what are considered the most relevant functional outcomes. We conducted a systematic review to identify the outcomes used in hip fracture randomized controlled trials (RCTs). We hypothesized that there had been an increase in numbers of PROs over time and the health status measure, SF-36, would be used the most. A database search and screening yielded 86 original trials. The mean Detsky score (and standard error) for quality was: 75.8% ± 1.76%. There was a trend in the increase of functional outcome; however, the SF-36 was used only in (10 out of 86) 11.6% trials. Both the ADL-Katz Index and HHS have lower respondent burden than the SF36 which may contribute to their frequent use in hip RCTs. There is a lack of applicable measures suitable for patients with dementia.

Antihypertensive drugs can cause hypotension in the elderly and such an effect may lead to fall injuries. This thesis examined the association between antihypertensive drugs and hip fracture risk among elderly patients during the initiation of monotherapy. This population-based self-controlled case series study used healthcare administrative databases to identify Ontario residents aged ≥ 66 years with a first prescription for a thiazide diuretic, angiotension II converting-enzyme inhibitor, angiotensin II receptor antagonist, calcium channel blocker or beta-adrenergic blocker. A cohort of newly treated hypertensive elderly was then linked to the occurrence of hip fractures from April 1, 2000 to March 31, 2009. We found that hypertensive elderly initiated on an antihypertensive drug had a 43% increased risk of having a hip fracture during the first 45 days of treatment, IRR 1.43 (95% CI 1.19-1.72). Initiating antihypertensive drugs in community-dwelling elderly should be approached with caution due to increased fracture risk.

Antihypertensive drugs can cause hypotension in the elderly and such an effect may lead to fall injuries. This thesis examined the association between antihypertensive drugs and hip fracture risk among elderly patients during the initiation of monotherapy. This population-based self-controlled case series study used healthcare administrative databases to identify Ontario residents aged ≥ 66 years with a first prescription for a thiazide diuretic, angiotension II converting-enzyme inhibitor, angiotensin II receptor antagonist, calcium channel blocker or beta-adrenergic blocker. A cohort of newly treated hypertensive elderly was then linked to the occurrence of hip fractures from April 1, 2000 to March 31, 2009. We found that hypertensive elderly initiated on an antihypertensive drug had a 43% increased risk of having a hip fracture during the first 45 days of treatment, IRR 1.43 (95% CI 1.19-1.72). Initiating antihypertensive drugs in community-dwelling elderly should be approached with caution due to increased fracture risk.

Hip fracture trials have used a wide range of patient-reported outcomes (PRO) suggesting a lack of consensus among clinicians on what are considered the most relevant functional outcomes. We conducted a systematic review to identify the outcomes used in hip fracture randomized controlled trials (RCTs). We hypothesized that there had been an increase in numbers of PROs over time and the health status measure, SF-36, would be used the most. A database search and screening yielded 86 original trials. The mean Detsky score (and standard error) for quality was: 75.8% ± 1.76%. There was a trend in the increase of functional outcome; however, the SF-36 was used only in (10 out of 86) 11.6% trials. Both the ADL-Katz Index and HHS have lower respondent burden than the SF36 which may contribute to their frequent use in hip RCTs. There is a lack of applicable measures suitable for patients with dementia.

Abstract The purposes of the present research were (1) to analyse and characterize the hip fractures treated at Oulu University Hospital during a one-year period using the special forms of the Standardized Audit of Hip Fractures in Europe (SAHFE) and to evaluate their value for quality control, (2) to compare gamma nail (GN) and dynamic hip screw (DHS) fixation for the treatment of trochanteric hip fractures, focusing especially on the functional aspects, (3) to compare the short-term outcome of gamma nail (GN) and dynamic hip screw (DHS) fixation for the treatment of subtrochanteric hip fractures, and (4) to examine the rate and reliability of the classification of basicervical hip fractures and the outcome of the operative methods used for their treatment. Oulu University Hospital joined the Swedish Hip Fracture Project (Rikshöft), aimed at developing the quality control of hip fracture treatment, in 1989, and this later evolved into a project called the Standardized Audit of Hip Fractures in Europe (SAHFE), funded by the European Commission. Registration of hip fractures on the SAHFE forms was common practise in Oulu from 1st September 1997 until the end of December 2003. SAHFE data collection forms were used in all four studies belonging to this thesis. There were 238 hip fracture patients during the one-year period of registration at Oulu University Hospital. The intracapsular / extracapsular fracture rate (60/40) and the female/male rate (80/20) seemed to be similar to those reported in the recent Finnish Health Care Register data. The most frequent method for treating cervical fractures was Austin-Moore hemiarthroplasty (68%) and that for trochanteric and subtrochanteric fractures GN fixation (86%). The SAHFE forms proved to be easy to use and practicable for evaluating the quality of hip fracture treatment. In a matched-pair study the short-term outcomes of the treatment of trochanteric fractures (after 4 months) were slightly better in the DHS group than in the GN group with respect to walking ability and mortality. The difference in mortality was at least partly due to the higher number of complications requiring re-operations associated with GN fixation. In the treatment of subtrochanteric hip fractures, there were four intraoperative complications (9.3%) in the GN group but none in the DHS group. On the other hand, postoperative complications were more common in the DHS group (20% vs. 2%). It is significant that all these complications in the DHS group occurred in Seinsheimer type IIIA fractures. It is concluded that, despite the perioperative problems associated with gamma nailing, this technique may be preferable to DHS fixation for specific fracture types with medial cortical comminutation, such as Seinsheimer type IIIA. Altogether 108 of the 1624 hip fractures were initially classified by the surgeons as basicervical fractures, but after a careful second look only 30 fulfilled all the criteria. The definitive rate of basicervical fractures was thus 1.8%. Treatment of basicervical fractures as trochanteric fractures proved superior to their treatment as cervical fractures, resulting in lower re-operation rates. In conclusions; this thesis suggests that SAHFE forms are very useful for evaluating the quality of hip fracture treatment. Both GN fixation and DHS fixation are effective methods for the treatment of trochanteric hip fractures in elderly patients; in less comminuted fractures, the DHS method is the preferred method of treatment whereas GN fixation is alternative treatment for more comminuted fractures. GN fixation is preferable for the subtrochanteric fratures. Basicervical fractures shoud be regarded clinically as extracapsular fractures and managed in a similar manner to trochanteric fractures.

The experiments presented in this thesis provide novel insight into two scarcely studied areas in the field of lateral hip impact biomechanics. The high energy nature of hip impacts requires high sampling rates for accurate study of hip impact dynamics. However, to date only optical motion capture, with relatively lower sampling rates (240-400 Hz), has been used to measure pelvic deflection during hip impact experiments with human participants. As such, the results from the first study compared the differences between two measurement systems (3D optical motion tracking and 2D high speed videography) in measuring common variables of impact biomechanics (peak force, time to peak force, peak deflection, time to peak deflection and energy absorbed). Although significant differences were seen between systems in measuring TFmax and Emax, the magnitude of differences were at or below 5% of the total magnitude of each measured variable. Furthermore, averaging impacts within a subject reduced the differences between systems for Emax. Furthermore, this study showed the effect of sampling rate on measuring hip impact dynamics, and how sampling at lower frequencies affects the aforementioned variables. Tests on the effect of sampling rate found differential effects contingent on the dependent variable measured. Sampling as low at 300 Hz, significantly reduced measures of Fmax and Dmax, but only by on average 0.7 and 0.5 %, respectively. Whereas measures of TFmax and TDmax increased by on average 9.5 and 6.8 %. Sampling Emax at 500 Hz and 300 Hz increased measures of impact absorption by 2.2 and 2.8 % respectively. Sampling at 4500 Hz was the lowest sampling rate that was not significantly different from 9000 Hz across all dependent variables. The second study in this thesis investigates the influence of contact area on load distribution during lateral hip impacts. In summary, this study shows that all three time-varying signals (Ft, FTt and Dt ) were significantly correlated with time-varying contact area (Ct). These results lend support to the possibility of modeling lateral hip impacts with contact models, but provide little support for a Hertzian model adaptation. Analysis on the relationships between body mass and BMI found both anthropometric measures to correlate significantly with peak impact force, but not with peak impact force directed to the greater trochanter. These results bring into question the feasibility of modeling hip fracture risk with body mass or BMI as inputs, without further investigating the distribution of impact force to the greater trochanter. In this study only contact area was significantly correlated with all measures of GT specific loading, and has never before been implemented in predictive modelling of hip fracture risk. Finally, this study found that although effective mass, total body mass and BMI were significantly correlated with the contact area at peak force, they only accounted for 21, 22 and 33% of the variance in CA. Altogether, this study sheds new light on the role that contact area plays in lateral hip impact loading and the importance of understanding load distribution during lateral hip impacts. It also highlights the importance of moving towards predictive models that incorporate more robust estimate of body composition and geometry, with hopes that these will better help estimate the risk of hip fracture. Overall, this thesis provides insight into the expected differences between measuring hip impact dynamics with two, relatively different measurement techniques. In addition, it highlights the need for further study on the relationship between contact geometry and hip fracture risk, something not currently implemented in most hip fracture risk models.

Osteoporosis is a major public health problem resulting in substantial hip fracture related morbidity. Using healthcare utilization data, we determined the 1- and 2-year direct attributable healthcare costs associated with hip fractures among Ontario seniors in comparison to a matched non-hip fracture cohort. Over a four-year period (2004-2008) we identified 22,418 females and 7,611 males with an incident hip fracture. Approximately 22% of females and 30% of males died in the first year after fracture. The mean attributable cost in the first year was $36,929 ($52,232 vs. $15,503) among females and $39,479 ($54,289 vs. $14,810) among males. Primary cost drivers included acute hospitalizations, complex continuing care, and rehabilitation. Attributable costs remained elevated into the second year, particularly among those who survived the first year ($9,017 females and $10,347 males). Results from this study will aid policy decision makers in allocating healthcare resources and help feed into future health economic analyses.

Osteoporosis is a major public health problem resulting in substantial hip fracture related morbidity. Using healthcare utilization data, we determined the 1- and 2-year direct attributable healthcare costs associated with hip fractures among Ontario seniors in comparison to a matched non-hip fracture cohort. Over a four-year period (2004-2008) we identified 22,418 females and 7,611 males with an incident hip fracture. Approximately 22% of females and 30% of males died in the first year after fracture. The mean attributable cost in the first year was $36,929 ($52,232 vs. $15,503) among females and $39,479 ($54,289 vs. $14,810) among males. Primary cost drivers included acute hospitalizations, complex continuing care, and rehabilitation. Attributable costs remained elevated into the second year, particularly among those who survived the first year ($9,017 females and $10,347 males). Results from this study will aid policy decision makers in allocating healthcare resources and help feed into future health economic analyses.

Abstract The treatment of hip fractures in the elderly has been under debate for decades. There is a lack of standardisation of treatment and rehabilitation and also concerning the measurements and follow-up times in studies on treatment. Two patient series with cervical hip fractures treated with Austin Moore hemiarthroplasty in Finland and hook pin osteosynthesis in Sweden were compared using matched-pair analysis in view of different age groups. Hip fracture treatments in six hospitals in Finland and one in Great Britain were surveyed. The adequacy of a short four-month follow-up was studied by comparing outcomes at four months and one year. Standardised Audit of Hip Fractures in Europe data collection sets were tested and used in three studies. Osteosynthesis resulted in lower one-year mortality but a higher reoperation rate in patients aged 55–75 years and was associated with a lesser need for walking aids, less pain and lower four-month mortality in patients aged 76–80 years. There were some differences in the patient characteristics and the methods of treatment between Great Britain and Finland. In Great Britain, more patients returned to their own homes, but one-year mortality after trochanteric fractures was higher. Hip fracture treatments and outcomes were quite similar between the six Finnish hospitals. There was a slight difference in adjusted postoperative mobility and mortality in two hospitals compared to the others. Six of the ten functional domains and residential status remained unchanged, while walking ability and four functional domains improved between four months and one year. The standardised data set was a practical and reliable way to acquire a great variety of information on hip fracture patients, treatments and outcomes. Hook pin osteosynthesis can be recommended for patients with cervical hip fractures younger than 80 years, whereas older patients can also be safely treated with Austin Moore hemiarthroplasty. The characteristics and outcomes of hip fracture patients were rather similar between Finland and Great Britain and between the different Finnish hospitals irrespective of the variety of methods used in treatment. Standardised Audit for Hip Fractures in Europe is a reliable data collection set and suitable as a basis of hip fracture surveys, audits and registers. Four-month follow-up is justified as the shortest feasible alternative in studies on rehabilitation and residential status after hip fractures.

We found no significant excess of fractures among Rochester, MN, residents with diabetes mellitus initially recognized in 1950-1969, but more recent studies elsewhere have documented an apparent increase in hip fracture risk. To explore potential explanations for any increase in fractures, we performed an historical cohort study among 1964 Rochester residents who first met glycemic criteria for diabetes in 1970-1994 (mean age, 61.7 ± 14.0 yr; 51% men). Fracture risk was estimated by standardized incidence ratios (SIRs), and risk factors were evaluated in Andersen-Gill time-to-fracture regression models. In 23,236 person-years of follow-up, 700 diabetic residents experienced 1369 fractures documented by medical record review. Overall fracture risk was elevated (SIR, 1.3; 95% CI, 1.2-1.4), but hip fractures were increased only in follow-up beyond 10 yr (SIR, 1.5; 95% CI, 1.1-1.9). As expected, fracture risk factors included age, prior fracture, secondary osteoporosis, and corticosteroid use, whereas higher physical activity and body mass index were protective. Additionally, fractures were increased among patients with neuropathy (hazard ratio [HR], 1.3; 95% CI, 1.1-1.6) and those on insulin (HR, 1.3; 95% CI, 1.1-1.5); risk was reduced among users of biquanides (HR, 0.7; 95% CI, 0.6-0.96), and no significant influence on fracture risk was seen with sulfonylurea or thiazolidinedione use. Thus, contrary to our earlier study, the risk of fractures overall (and hip fractures specifically) was increased among Rochester residents with diabetes, but there was no evidence that the rise was caused by greater levels of obesity or newer treatments for diabetes.