Hip fractures : a European perspective

Abstract

In 1986 the first prospectively designed multinational survey on incidence of and risk factors for hip fracture utilising a standardised design was initialised. The MEDOS study (Mediterranean osteoporosis) covered 14 centres in six Mediterranean countries, with a population of 3 million individuals aged fifty years or older. In one year, 2,768 hip fractures occurred in women and 934 in men. The corresponding incidence was 21.4/10,000 women and 9.9/10,000 men, rates that are lower than those of Northern Europe, although probably valid. The variation between centres within one country ranged from 1.3-fold to 1.8-fold, and within the total area there was a 7-fold variability in men and a 16-fold in women. An explanation may be that increased longevity of populations is largely achieved by the survival of frail individuals, more susceptible to chronic diseases. If this is true the age-specific incidence in the Southern part of Europe will increase, as it has been reported from Northern America and Northern Europe, although the secular trend in the oldest populations seems to have turned.

For long-term prevention (20-50 years), five life-style related and potentially revertible factors were identified: low BMI, low consumption of milk, low physical activity, low exposure to sunlight, and low consumption of tea, together accounting for 56% of the female risk. A medium- term perspective of prevention (5-20 years) gives the menopausal effect, lasting for 25 years and resulting in a risk increase of 100%. Whether RRT shall be counselled, at what time, and of what duration cannot be read from these observational data. RCT:s are required, and should be initialised without delay, as large European cohorts currently become menopausal. The effective level of milk consumption in order to protect from hip fractures was surprisingly low, corresponding to 500 mg calcium per day.

20% of all hip fracture patients live in institutions, most of them demented. The performance in a mental/functional test was predictive for hip fracture, with a RR of 5.7 in the most affected group, signifying that a target group for short-term (0-5 years) prevention is easily identified. With the protection of shock absorbing hip protectors and supplementation with calcium and vitamin D, 10% of all hip fractures can be prevented.

No programs aiming at reducing falls in the elderly have proven effective in preventing from hip fractures. One reason is the complex pattern of interaction between the individual and its environment. 85% of all fracture patients suffered from severe comorbidity, were treated with antihypertensives and/or psychotropic drugs, had impaired visual acuity or were exposed to environmental factors, judged to elevate the risk of falling. However, each specific combination of intrinsic and extrinsic risk factors was present in only few patients. Prevention obviously must be tailored, based on the knowledge on what specific risk combination the specific elderly person is exposed to, and on epidemiological knowledge. The responsibility is shared between the individual and his/her GP.