Orthopaedic management improves the rate of early osteoporosis treatment after hip fracture. A randomized clinical trial. Development and delivery of patient treatment in the Trondheim Hip Fracture Trial. A new geriatric in-hospital pathway for elderly patients with hip fracture Use of Nonpharmacologic Interventions for Pain and Anxiety After Total Hip and Total Knee Arthroplasty Translating research into practice intervention improves management of acute pain in older hip fracture patients. Fracture prevention service to bridge the osteoporosis care gap The management of intracapsular hip fractures in the 'young elderly' internal fixation or total hip replacement? Fascia Iliaca Compartment Blockade for Acute Pain Control in Hip Fracture Patients: A Randomized, Placebo-controlled Trial Osteoporosis case manager for patients with hip fractures: results of a cost-effectiveness analysis conducted alongside a randomized trial. Comprehensive care improves health outcomes among elderly Taiwanese patients with hip fracture. Depression and osteoarthritis. The effect of emergency department crowding on the management of pain in older adults with hip fracture. Evaluating the cost-effectiveness of fall prevention programs that reduce fall-related hip fractures in older adults. Effect of osteosynthesis, primary hemiarthroplasty, and non-surgical management for displaced four-part fractures of the proximal humerus in elderly: a multi-centre, randomised clinical trial Counseling, quality of life, and acute postoperative pain in elderly patients with hip fracture Facilitated bone mineral density testing versus hospital-based case management to improve osteoporosis treatment for hip fracture patients: additional results from a randomized trial. Use of an Intramedullary Hip-Screw Compared with a Compression Hip-Screw with a Plate for Intertrochanteric Femoral Fractures. 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HipWatch: osteoporosis investigation and treatment after a hip fracture: a 6-month randomized controlled trial. Epidural infusion of bupivacaine and fentanyl reduces perioperative myocardial ischaemia in elderly patients with hip fracture – a randomized controlled trial A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly. A randomised, controlled trial. Physical behavior and function early after hip fracture surgery in patients receiving comprehensive geriatric care or orthopedic care--a randomized controlled trial. Preoperative traction in patients with hip fractures. 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BACKGROUND Although osteoporosis is strongly associated with hip fractures , the initiation of osteoporosis treatment following hip fractures occurs at surprisingly low rates of between 5 % and 30 % . Currently , most patients receiving treatment have been referred back to their primary care physician for osteoporosis management . The purpose of this study was to compare the effect of osteoporosis management initiated by the orthopaedic team and osteoporosis management initiated by the primary care physician on the rates of treatment at six months . METHODS A prospect i ve r and omized trial was conducted to assess the difference in the rate of osteoporosis treatment  when an in-house assessment of osteoporosis was initiated by the orthopaedic surgeon and follow-up was conducted in a specialized orthopaedic osteoporosis clinic compared with osteoporosis education and " usual " care . RESULTS Sixty-two patients were enrolled in the study . Thirty-one patients each were in the control and intervention groups . The percentage of patients who were on pharmacologic treatment for osteoporosis  at six months after the fracture was significantly greater when the evaluation was initiated by the orthopaedic surgeon and was managed in a specialized orthopaedic osteoporosis clinic ( 58 % ) than when treatment was managed by a primary care physician ( 29 % ) ( p = 0.04 ) . CONCLUSIONS An active role by orthopaedic surgeons in the management of osteoporosis improves the rate of treatment at six months following a hip fracture Background Hip fractures are common among frail elderly persons and often have serious consequences on function , mobility and mortality . Traditional treatment of these patients is performed in orthopedic departments without additional geriatric assessment . However , studies have shown that interdisciplinary geriatric treatment may be beneficial compared to traditional treatment . The aim of the present study is to investigate whether treatment of these patients in a Department of Geriatrics ( DG ) during the entire hospital stay gives additional benefits as compared to conventional treatment in a Department of Orthopaedic Surgery ( DOS ) . Findings A new clinical pathway for in-hospital treatment of hip fracture patients was developed . In this pathway patients were treated pre- and postoperatively in DG .  Comprehensive geriatric assessment  was performed as an interdisciplinary , multidimensional , systematic assessment of all patients focusing on each patient ’s capabilities and limitations as recommended in guidelines and systematic review s. Identification and treatment of co-morbidities , pain relief , hydration , oxygenation , nutrition , elimination , prevention and management of delirium , assessment of falls and osteoporosis were emphasized .  Discharge planning  started as early as possible . Initiation of rehabilitation with focus on early mobilisation and development of individual plans was initiated in hospital and continued after discharge from hospital . Fracture specific treatment was based upon st and ard treatment for the hospital , expert opinions and a review of the literature . Conclusion A new treatment program for old hip fracture patients was developed , introduced and run in the DG , the potential benefits of which being compared with traditional care of hip fracture patients in the DOS in a r and omised clinical trial PURPOSE The purpose of this study was to compare pain and anxiety in orthopaedic patients scheduled for elective total hip or knee arthroplasty who have received a kit of nonpharmacologic strategies for pain and anxiety in addition to their regularly prescribed analgesics to those who receive the usual pharmacologic management alone . DESIGN Descriptive comparative and correlational design using surveys and chart audits . SAMPLE Sixty-five patients r and omized to receive usual care or usual care plus a kit of nonpharmacologic strategies .  FINDINGS Patients who received the kit used nonpharmacologic measures for pain and anxiety more often than patients who did not receive the kit . The kit group tended to use less opioid and have less anxiety on postoperative day 1 ( not statistically significant ) and use significantly less opioid on postoperative day 2 than the patients who did not receive the kit . There were no between-group differences in pain intensity . There were significant correlations among postoperative pain intensity , opioid use , and anxiety . The coping method of diverting attention was related to lower present ( now ) pain scores , and ignoring the pain was associated with higher worst pain . DISCUSSION Providing a kit of nonpharmacologic strategies can increase the use of these methods for postoperative pain and anxiety and decrease the amount of opioid taken . The influence of coping strategies in acute postoperative pain needs to be examined further OBJECTIVE To test an interdisciplinary , multifaceted , translating research into practice ( TRIP ) intervention to ( a ) promote adoption , by physicians and nurses , of evidence -based ( EB ) acute pain management practice s in hospitalized older adults , ( b ) decrease barriers to use of EB acute pain management practice s , and ( c ) decrease pain  intensity of older hospitalized adults . STUDY DESIGN Experimental design with the hospital as the unit of r and omization . STUDY SETTING Twelve acute care hospitals in the Midwest . DATA SOURCES ( a ) Medical records ( MRs ) of patients > or = 65 years or older with a hip fracture admitted before and following implementation of the TRIP intervention and ( b ) physicians and nurses who care for those patients . DATA COLLECTION Data were abstract ed from MRs and questions distributed to nurses and physicians . PRINCIPAL FINDINGS The Summative Index for Quality of Acute Pain Care ( 0 - 18 scale ) was significantly higher for the experimental ( 10.1 ) than comparison group ( 8.4 ) at the end of the TRIP implementation phase . At the end of the TRIP implementation phase , patients in the experimental group had a lower mean pain intensity rating than those in the comparison group ( p<.0001 ) . CONCLUSION The TRIP intervention improved quality of acute pain management of older adults hospitalized with a hip fracture Background A care gap exists between the health care needs of older persons with fragility fractures and the therapeutic answers they receive . The Fracture Prevention Service ( FPS ) , a tailored in-hospital model of care , may effectively bridge the osteoporosis care gap for hip-fractured older persons . The purpose of this study was to evaluate the efficacy of the FPS in targeting persons at high risk of future fracture and to improve their adherence to treatment . Methods This was a prospect i ve observational study conducted in a teaching hospital with traumatology and geriatric units , and had a pre-intervention and post-intervention phase . The records of 172 participants were evaluated in the pre-intervention phase , while data from 210 participants were gathered in the post-intervention phase . All participants underwent telephone follow-up at 12 months after hospital discharge . The participants were patients aged ≥65 years admitted to the orthopedic acute ward who underwent surgical repair of a proximal femoral fracture . A multidisciplinary integrated model of care was established . Dedicated pathways were implemented in clinical practice to optimize the identification of high-risk persons , improve their evaluation through bone mineral density testing and blood examinations , and initiate an appropriate treatment for secondary prevention of falls and fragility fractures . Results Compared with the pre-intervention phase , more hip-fractured persons received bone mineral density testing ( 47.62 % versus 14.53 % , P<0.0001 ) , specific pharmacological treatments ( 48.51 % versus 17.16 % , P<0.0001 ) , and an appointment for evaluation at a fall and fracture clinic ( 52.48 % versus 2.37 % , P<0.0001 ) in the post-intervention phase . Independent of some confounders , implementation of the FPS was positively associated with recommendations for secondary fracture prevention at discharge ( P<0.0001 ) and with 1-year adherence to pharmacological treatment ( P<0.0001 ) . Conclusion The FPS is an effective multidisciplinary integrated model of care to optimize identification of older persons at highest risk for fragility fracture , to improve their clinical management , and to increase adherence to prescriptions There is a lack of consensus about how to treat intracapsular hip fractures in the ' young elderly ' ( 50 - 75 years ) . Evidence for older more mobile patients seems to point towards Internal Fixation ( IF ) for undisplaced fractures and Total Hip Replacement ( THR ) for displaced fractures . Radiographs of 263 patients from the Norfolk and Norwich University Hospital , who have suffered an intracapsular hip fracture between 2000 - 2009 were review ed . The complication and mortality rates were noted . A Hip function question naire ( Oxford hip score ( OHS ) ) and Numeric pain score ( NPS ) were sent out to patients , then methods of treatment ( IF and THR ) were compared . In displaced fractures THR compared favourably to IF , OHS ( 16.0 vs. 20.0 p 0.029 ) , NPS ( 2.0 vs. 4.0 p 0.007 ) , complications ( Odds Ratio ( OR ) 2.90 ; p 0.006 ) and death rate ( OR 3.61 ; p 0.007 ) . Although not statistically significant when stratified for age , the youngest age group ( 50 - 60 ) still achieved better function with a THR ( 13.0 vs. 18.0 ; p 0.129 ) . There was little difference in the results for undisplaced fractures . This retrospective cross-sectional study showed IF is associated with a much higher complication rate than THR for patients who sustained a displaced hip fracture . THR also showed a better functional outcome and reduced pain .  IF should be used in undisplaced fractures as there was no difference in functional outcome or complication rate . A large r and omised controlled trial is needed to confirm these results Background : Hip fracture patients are in severe pain upon arrival at the emergency department . Pain treatment is traditionally based on systemic opioids . No study has examined the effect of fascia iliaca compartment blockade ( FICB ) in acute hip fracture pain management within a double-blind , r and omized setup . Methods : Forty-eight patients with suspected hip fracture were included immediately after arrival in the emergency department , before x-ray confirmation of their fracture . Included patients were r and omly assigned to two groups of 24 . In the FICB group , the patients received an FICB with 1.0 % mepivacaine and a placebo intramuscular injection of isotonic saline . In the morphine group , the patients received a placebo FICB with 0.9 % saline and an intramuscular injection of 0.1 mg/kg morphine . Patients received intravenous rescue morphine when necessary . Results : Maximum pain relief was superior in the FICB group both at rest ( P < 0.01 ) and on movement ( P = 0.02 ) . The median total morphine consumption was 0 mg ( interquartile range , 0–0 mg ) in the FICB group and 6 mg ( interquartile range , 5–7 mg ) in the morphine group ( P < 0.01 ) . More patients ( P = 0.05 ) were se date d in the morphine group at 180 min after block placement as compared with the FICB group . Conclusion : Pain relief was superior at all times and at all measurements in the FICB group . The study supports the use of FICB in acute management of hip fracture pain because it is an effective , easily learned procedure that also may reduce opioid side effects in this fragile , elderly group of patients BACKGROUND In a r and omized trial of patients with hip fractures , we previously demonstrated that a hospital-based case manager could increase rates of appropriate osteoporosis treatment to 51 % compared with 22 % for usual care ( P < .001 ) . Alongside that trial , we conducted an economic analysis . METHODS Patients with hip fractures were r and omized to usual care ( n = 110 ) or a case manager ( n = 110 ) and followed up for 1 year . Time-motion studies were used to determine intervention costs . From a third-party health care payer perspective and over the patient 's remaining lifetime , a Markov decision-analytic model was constructed to determine  cost-effectiveness  of the intervention compared with usual care .  Costs and benefits were discounted at 3 % and expressed in 2006 Canadian dollars . RESULTS The intervention cost CaD $ 56 per patient . Compared with usual care , the intervention strategy was dominant : for every 100 patients case managed , 6 fractures ( 4 hip fractures ) were prevented , 4 quality -adjusted life-years were gained , and CaD $ 260 000 was saved by the health care system . Irrespective of the number of patients case managed , the intervention reached a break-even threshold within 2 years . The intervention dominated usual care over the entire spectrum of 1-way sensitivity analyses and was cost-saving in 82 % of probabilistic model simulations . CONCLUSIONS Compared with usual care , we found that using a case manager for patients with hip fractures increased rates of appropriate osteoporosis treatment . The intervention dominated usual care , and the analysis suggests that systems implementing an intervention similar to ours should expect to see a reduction in fractures , gains in life expectancy , and substantial cost savings . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00175175 BACKGROUND Few studies have investigated the effects of care models that combine interdisciplinary care with nutrition consultation , depression management , and fall prevention in older persons with hip fracture . The purpose of this study was to compare the effects of a comprehensive care program with those of interdisciplinary care and usual care for elderly patients with hip fracture . METHODS A r and omized experimental trial was used to explore outcomes for 299 elderly patients with hip fracture receiving three treatment care models : interdisciplinary care ( n = 101 ) , comprehensive care ( n = 99 ) , and usual care ( n = 99 ) .  Interdisciplinary care included geriatric consultation , continuous rehabilitation , and discharge planning with post-hospital services . Comprehensive care consisted of interdisciplinary care plus nutrition consultation , depression management , and fall prevention . Usual care included only in-hospital rehabilitation without geriatric consultation , in-home rehabilitation , and home environmental assessment . RESULTS Participants in the comprehensive care group had better self-care ability ( odds ratio , OR = 3.19 , p < .01 ) and less risk of depression ( OR = 0.48 , p < .01 ) than those who received usual care . The comprehensive care group had less risk of depression ( OR = 0.51 , p < .05 ) and of malnutrition ( OR = 0.48 , p < .05 ) than the interdisciplinary care group during the first year following discharge . Older persons with hip fracture benefitted more from the comprehensive care program than from interdisciplinary care and usual care . CONCLUSIONS Older persons with hip fracture benefitted more from comprehensive care including interdisciplinary care and nutrition consultation , depression management , and fall prevention than simply interdisciplinary care Depression is significant among patients with arthritis and musculoskeletal illnesses . However , the impact of depression on osteoarthritis has not been extensively studied . This article highlights the close links between these 2 prevalent chronic conditions , and the associated individual and societal burden . Results from a large clinical trial of depressed older patients with arthritis showed that a focused , collaborative depression care intervention not only decreased depression but also improved arthritis-associated outcomes , such as pain severity and arthritis-related limitations in daily activities . Relative to patients given usual care , patients receiving intervention also reported better health status and higher quality of life . Analyses of the depression interventions uncovered a reciprocal interrelation between depression and pain . Higher severity of either depression or pain decreased the benefits of systematic depression treatment and was associated with worse pain and depression outcomes . Current approaches to management of depression and arthritis do not reflect readily-available evidence -based treatment . A pilot study using a combined approach to address both depression and pain problems among elderly patients with depression and osteoarthritis suggested that benefits for depression , pain , and functional outcomes are strengthened by providing both  pain and depression care management . An integrated depression and pain program using evidence d-based pharmacologic and nonpharmacologic treatments is needed to achieve optimal depression and pain outcomes . Currently , a r and omized trial is under way to evaluate effectiveness of a combined pain and depression intervention using pharmacologic and nonpharmacologic therapies . Key intervention components in these 2 innovative and integrated depression and pain programs can guide clinicians to treat both depression and pain with more focus and intensity OBJECTIVES To evaluate the effect of emergency department ( ED ) crowding on assessment and treatment of pain in older adults . DESIGN Retrospective review of ED records from a prospect i ve cohort study . SETTING Urban , academically affiliated , tertiary medical center . PARTICIPANTS One hundred fifty-eight patients , aged 50 and older , evaluated and hospitalized from the ED with hip fracture . MEASUREMENTS Patient-related risk factors : age , sex , nursing home residence , ED triage status , dementia , Acute Physiology in Age and Chronic Health Evaluation II physiological score , and R AND comorbidity score . ED crowding risk factors : ED census and mean length of stay . OUTCOMES documentation of pain assessment , time to pain assessment , time to pain treatment , patients reporting pain receiving analgesia , and meperidine use . RESULTS Mean age was 83 ( range 52 - 101 ) , 81.0 % of patients complained of pain , mean time to pain assessment was 40 minutes ( range 0 - 600 ) , time to treatment was 141 minutes ( range 10 - 525 ) , and mean delay to treatment was 122 minutes ( range 0 - 526 ) . Of those with pain , 35.9 % received no analgesia , 7.0 % received nonopioids , and 57.0 % received opioids . Of those receiving opioids , 32.8 % received meperidine . ED crowding at census levels greater than 120 % bed capacity was significantly associated with a lower likelihood of documentation of pain assessment ( P = .05 ) and longer times to pain assessment ( P = .01 ) . CONCLUSION Older adults with hip fracture are at risk for under assessment of pain , considerable delays in analgesic administration after pain is identified , and treatment with inappropriate analgesics ( e.g. , meperidine ) in the ED . Higher levels of ED census are significantly associated with poorer pain management OBJECTIVES To model the incremental cost-utility of seven interventions reported as effective for preventing falls in older adults . DESIGN Mathematical epidemiological model populated by data based on direct clinical experience and a critical review of the literature . SETTING Model represents population level interventions . PARTICIPANTS No human subjects were involved in the study . MEASUREMENS : The last Cochrane data base review and meta-analyses of r and omized controlled trials categorized effective fall-prevention interventions into seven groups : medical management ( withdrawal ) of psychotropics , group tai chi , vitamin D supplementation , muscle and balance exercises , home modifications , multifactorial individualized programs for all elderly people , and multifactorial individualized treatments for high-risk frail elderly people . Fall-related hip fracture incidence was obtained from the literature . Salary figures for health professionals were based on Bureau of Labor Statistics data . Using an integrated healthcare system perspective , healthcare costs were estimated based on practice and studies on falls in older adults . Base case incremental cost utility ratios were calculated , and probabilistic sensitivity analyses were conducted . RESULTS Medical management of psychotropics and group tai chi were the least-costly , most-effective options , but they were also the least studied . Excluding these interventions , the least-expensive , most-effective options are  vitamin D supplementation and home modifications . Vitamin D supplementation costs less than home modifications , but home modifications cost only $ 14,794/ quality -adjusted life year ( QALY ) gained more than vitamin D. In probabilistic sensitivity analyses excluding management of psychotropics and tai chi , home modification is most likely to have the highest economic benefit when QALYs are valued at $ 50,000 or $ 100,000 . CONCLUSION Of single interventions studied , management of psychotropics and tai chi reduces costs the most . Of more-studied interventions , home modifications provide the best value . These results must be interpreted in the context of the multifactorial nature of falls Background Fractures of the proximal humerus are common injuries and account for 4–5 percent of all fractures , second only to hip and wrist fractures . The incidence is positively correlated with age and osteoporosis , and is likely to increase . Displaced four-part fractures are among the most severe injuries , accounting for 2–10 percent of proximal humeral fractures . The optimal intervention is disputed . Two previous r and omised trials were very small and involved a noticeable risk of bias , and systematic review s consequently conclude that there is inadequate basis for evidence -based treatment decisions . We aim to compare the effect of osteo synthesis with angle-stable plate with non-surgical management , and the effect of  primary hemiarthroplasty  with both osteo synthesis and non-surgical management . Methods / Design We will conduct a r and omised , multi-centre , clinical trial including patients from ten national shoulder units within a two-year period . We plan to include 162 patients . A central r and omisation unit will allocate patients . All patients will receive a st and ardised three-month rehabilitation program of supervised physiotherapy regardless of treatment allocation . Patients will be followed at least one year . The primary outcomes will be the overall score on the Constant Disability Scale , and its pain subscale , measured at 12 months . A blinded physiotherapist will carry out the assessment s. Other secondary outcomes are Oxford Shoulder Score , and general health status ( Short Form-36 ) Introduction Hip fractures represent one of the most important causes of morbidity and mortality in elderly people . Anxiety and depression affect their quality of life and increase pain severity , and have adverse effects on functional recovery . Recent World Health Organization guidelines emphasize that therapeutic regimes need to be individualized and combined with psychological support . This study was launched with the primary endpoint of assessing if and to what extent client-centered therapy affects the perception of pain , reduces anxiety and depression , and increases the quality of life of elderly patients with hip fracture . Material s and methods Forty patients were admitted to the Orthopedic and Trauma Surgery ward for hip fracture . Patients were r and omly divided into two subgroups : ( 1 ) case ( group C ) , had to receive patient-centered counseling throughout the hospitalization ; and ( 2 ) control ( group NC ) , receiving the analgesic treatment without receiving counseling .  Short Form-36-item Health Survey Question naire , State – Trait Anxiety Inventory , and Hamilton Rating Scale for Depression scores were recorded before any treatment , at discharge , and after 30 days . Pain levels were evaluated by means of Visual Analog Scale every 12 hours during the hospitalization from the day of surgery until day 5 . Results The hierarchical clustering analysis identified before any treatment were two clusters based on different physical functioning perceptions and role limitations , which were due to physical and emotional problems . Counseling did have a positive impact on quality of life on all patients , but in a more relevant way if patients were low functioning upon admittance to the ward . Anxiety and depression decreased in patients undergoing counseling , and their pain levels were lower than among patients not receiving it . Conclusion This study reveals that hip fracture patients can be clustered on the basis of Short Form-36 baseline scores . Counseling affects the evolution of mental and physical status in these patients , and the major benefit is reported in patients whose quality of life perception is worse after the trauma . Decreasing anxiety and depression levels , as well as more satisfying pain management , assessed by means of specific tests , confirm the effectiveness of counseling in elderly patients with hip fracture OBJECTIVE We previously demonstrated that a case manager intervention improved  osteoporosis  ( OP ) treatment within 6 months of hip fracture compared with usual care . The second phase of the r and omized trial compared a less intensive intervention , facilitated bone mineral density ( BMD  )  testing , with usual care and the case manager intervention . METHODS We initially r and omized 220 hip fracture patients to either an OP case manager intervention or usual care . After completing the original trial at 6 months postfracture , usual care patients were reallocated to facilitated BMD testing ; BMD tests were arranged and results sent to primary care physicians . Main outcomes ( bisphosphonate treatment , BMD tests , receipt of appropriate care ) were reascertained 1 year following hip fracture and compared with outcomes achieved by the OP case manager intervention and usual care . RESULTS Compared with usual care , facilitated BMD testing increased testing from 29 % to 68 % ( P < 0.001 ) , bisphosphonate use from 22 % to 38 % ( P < 0.001 ) , and receipt of appropriate care from 26 % to 45 % ( P < 0.001 ) . The more intensive ( 70 versus 30 minutes ) and expensive ( $ 56 versus $ 24 Canadian per patient ) OP case manager intervention led to significantly higher bisphosphonate use ( 54 % versus 38 % ; P = 0.03 ) , receipt of appropriate care ( 71 % versus 45 % ; P < 0.001 ) , and more BMD testing ( 80 % versus 68 % ; P = 0.06 ) than usual care followed by facilitated BMD testing . CONCLUSION Compared with usual care , 2 different inexpensive interventions result ed in significant increases in appropriate management of OP after hip fracture . The magnitude of improvements achieved was directly related to the intensity of the interventions One hundred elderly patients who had an intertrochanteric femoral fracture were r and omized to treatment with a compression hip-screw with a plate ( fifty patients ) or a  new intramedullary device , the intramedullary hip-screw ( fifty patients ) . All patients were followed prospect ively for one year or until death . A detailed assessment of the functional status and the plain radiographs of the hip was performed one , three , six , and twelve months postoperatively . The two treatment groups were strictly comparable . The operative time needed to insert the intramedullary hip-screw was significantly greater than that needed to insert the compression hip-screw with the plate ( p = 0.02 ) , but use of the intramedullary hip-screw was associated with less estimated intraoperative blood loss ( p = 0.011 ) . The prevalence of perioperative complications , such as bronchopneumonia , cardiac failure , and urinary tract infection , was comparable in the two treatment groups . There were one intraoperative fracture of the femoral shaft and two intraoperative fractures of the greater trochanter in the group managed with the intramedullary hip-screw . One patient had pulling-out of the compression hip-screw on the seventh postoperative day . Four patients had a trochanteric wound hematoma , without infection , after insertion of an intramedullary hip-screw . All but one of the fractures healed . The one non-union , which was in a patient who had a compression hip-screw , was treated with a hemiarthroplasty . The mortality rate was similar in the two treatment groups . The patients who had an intramedullary hip-screw had , on the average , significantly better mobility at one ( p < 0.0001 ) and three months ( p = 0.0013 ) postoperatively . This difference was no longer seen at six and twelve months , although the patients who had an intramedullary hip-screw still had significantly better walking ability outside the home at those time-periods ( p = 0.05 ) . The compression hip-screw was removed from two patients because of pain in the mid-portion of the thigh , which had begun after consolidation of the fracture . Fourteen patients who had an intramedullary hip-screw had cortical hypertrophy at the level of the tip of the nail at twelve months postoperatively . Cortical hypertrophy was significantly related to the use of two interlocking screws ( p = 0.02 ) . Six of these patients also had pain in the mid-portion of the thigh , and the nail had been locked with two screws in five of them . Three of the six patients had the hardware removed because of the pain , and the symptoms resolved . A seventh patient had pain without cortical hypertrophy . The intramedullary hip-screw device was associated with significantly less sliding of the lag-screw and subsequent shortening of the limb in the region of the thigh ( p = 0.012 and 0.019 , respectively ) ; these differences were more pronounced when the unstable fractures in the two treatment groups were compared ( p < 0.001 ) BACKGROUND Elderly patients with hip fracture have been found to benefit from subacute care interventions that usually comprise usual care with added geriatric intervention , early rehabilitation , and supported discharge . However , no studies were found on the effects of combining subacute care and health-maintenance interventions on health outcomes for elders with hip fracture . OBJECTIVES To compare the effects of an interdisciplinary comprehensive care programme with those of subacute care and usual care programmes on health-related quality of life ( HRQoL ) for elderly patients with hip fracture . DESIGN R and omised controlled trial . SETTING S A 3000-bed medical centre in northern Taiwan . PARTICIPANTS Patients with hip fracture ( N=299 ) were r and omised into three groups : subacute care ( n=101 ) , comprehensive care ( n=99 ) , and usual care ( n=99 ) . METHODS Subacute care included geriatric consultation , continuous rehabilitation , and discharge planning . Comprehensive care consisted of subacute care plus health-maintenance interventions to manage depressive symptoms , manage malnutrition , and prevent falls . Usual care included only 1 - 2 in-hospital rehabilitation sessions , discharge planning without environmental assessment , no geriatric consultation , and no in-home rehabilitation .  HRQoL was measured using the Medical Outcomes Study Short-Form 36 Taiwan version at 1 , 3 , 6 , and 12 months after discharge . RESULTS Participants in the comprehensive care group improved more in physical function , role physical , general health and mental health than those in the usual care group . The subacute care group had greater improvement in physical function , role physical , vitality , and social function than the usual care group . The intervention effects for both comprehensive and subacute care increased over time , specifically from 6 months after hip fracture onward , and reached a maximum at 12 months following discharge . CONCLUSIONS Both comprehensive care and subacute care programmes may improve health outcomes of elders with hip fracture . Our results may provide a reference for health care providers in countries using similar programmes with Chinese/Taiwanese immigrant population The purpose of the current study was to evaluate the effectiveness of a multidisciplinary Hip Fracture Service in the treatment of hip fractures in elderly patients . Baseline information and hospital outcomes were compared for 510 patients over the age of 65 with hip fracture treated before and after the institution of the Hip Fracture Service .  Data included basic demographic data , admission laboratory results , surgical information , number of comorbidities , mortality , medical complications , discharge information , time to surgery , and length of stay in hospital . The demographics of the two groups of patients were similar . Patients treated as part of the Hip Fracture Service had fewer medical complications ( 36 % vs. 51 % ) , more often had surgery within 24 hours ( 63 % vs. 35 % ) , and had shorter hospital stays ( mean , 5.7 days vs. 8.1 days ) than patients treated before the Hip Fracture Service . These findings provide the rationale for a prospect i ve , r and omized trial of the service BACKGROUND Patients who survive hip fracture are at high risk of recurrent fractures , but rates of osteoporosis treatment 1 year after sustaining a fracture are less than 10 % to 20 % . We have developed an osteoporosis case manager intervention . The case manager educated patients , arranged bone mineral density tests , provided prescriptions , and communicated with primary care physicians . The intervention was compared with usual care in a r and omized controlled trial . METHODS We recruited from all hospitals that participate in the Capital Health system ( Alberta , Canada ) , including patients 50 years or older who had sustained a hip fracture and excluding those who were receiving osteoporosis treatment or who lived in a long-term care facility . Primary outcome was  bisphosphonate therapy 6 months after fracture ; secondary outcomes included bone mineral density testing , appropriate care ( bone mineral density testing and treatment if bone mass was low ) , and intervention costs . RESULTS We screened 2219 patients and allocated 220 , as follows : 110 to the intervention group and 110 to the control group . Median age was 74 years , 60 % were women , and 37 % reported having had previous fractures . Six months after hip fracture , 56 patients in the intervention group ( 51 % ) were receiving bisphosphonate therapy compared with 24 patients in the control group ( 22 % ) ( adjusted odds ratio , 4.7 ; 95 % confidence interval , 2.4 - 8.9 ; P < .001 ) . Bone mineral density tests were performed in 88 patients in the intervention group ( 80 % ) vs 32 patients in the control group ( 29 % ) ( P < .001 ) . Of the 120 patients who underwent bone mineral density testing , 25 ( 21 % ) had normal bone mass . Patients in the intervention group were more likely to receive appropriate care than were patients in the control group ( 67 % vs 26 % ; P < .001 ) . The average intervention cost was $ 50.00 per patient . CONCLUSION For a modest cost , a case manager was able to substantially increase rates of osteoporosis treatment in a vulnerable elderly population at high risk of future fractures BACKGROUND Treatment of osteoporosis following a hip fracture has been notoriously poor . Many efforts have been made to improve treatment rates . The purpose of this study was to determine whether a perioperative inpatient intervention program , involving patient education and providing a list of questions for the primary care physician , increased the percentage of patients in whom osteoporosis was addressed following a hip fracture . METHODS A prospect i ve , r and omized trial involving eighty patients who had been admitted to an academic medical center with a low-energy hip fracture was conducted . During their hospitalization , the study group patients were engaged in a fifteen-minute discussion regarding the association between osteoporosis and hip fractures , the efficacy of dual-energy x-ray absorptiometry scans in the diagnosis of osteoporosis and of bisphosphonates in its treatment , and the importance of medical follow-up for osteoporosis management . These patients were also provided with five questions regarding osteoporosis treatment to be given to their primary medical physician , and they were reminded about the questions during a follow-up telephone call six weeks later . The patients in the control group received a brochure describing methods for preventing falls . Both groups were contacted by telephone at six months after discharge to determine whether osteoporosis had been addressed . Positive indicators of intervention included assessment of bone mineral density with dual-energy x-ray absorptiometry and initiation of antiresorptive therapy .  RESULTS The average age in each group was eighty-two years , and 78 % of the patients were female . Four patients in each group did not survive through the six-month follow-up period and were excluded from the trial . Fifteen ( 42 % ) of the thirty-six patients who had been r and omized to the study group , compared with only seven ( 19 % ) of the thirty-six patients in the control group , had their osteoporosis addressed by their primary physician . This difference between the groups was significant ( p = 0.036 ) . CONCLUSIONS Patients who were provided with information and questions for their primary care physician about osteoporosis were more likely to receive appropriate therapeutic intervention than were patients who had not received the information and questions . Orthopaedic surgeons have a unique opportunity to improve the rate of osteoporosis treatment in the perioperative period following a hip fracture by educating patients and directing them toward channels for long-term osteoporosis management Introduction : Hip fractures are common in the elderly patients with an incidence of 320 000 fractures/year in the United States , representing a health-care cost of US$ 9 to 20 billion . Hip fracture incidence is projected to increase dramatically . Hospitals must modify clinical models to accommo date this growing burden . Comanagement strategies are reported in the literature , but few have addressed orthopedic-hospitalist models . An orthopedic-hospitalist comanagement ( OHC ) service was established at our hospital to manage hip fracture patients . We sought to determine whether the OHC ( 1 ) improves the efficiency of hip fracture management as measured by inpatient length of stay ( LOS ) and time to surgery ( TTS ) and ( 2 ) whether our results are comparable to those reported in hip fracture comanagement literature . Methods : A comparative retrospective– prospect i ve cohort study of patients older than 60 years with an admitting diagnosis of hip fracture was conducted to compare inpatient LOS and TTS for hip fracture patients admitted 10 months before ( n = 45 ) and 10 months after implementation ( n = 54 ) of the OHC  at a single academic hospital . Secondary outcome measures included percentage of patients taken to surgery within 24 or 48 hours , 30-day readmission rates , and mortality . Outcomes were compared to comanagement study results published in MEDLINE -indexed journals . Results : Patient cohort demographics and comorbidities were similar . Inpatient LOS was reduced by 1.6 days after implementation of the OHC ( P = .01 ) without an increase in 30-day readmission rates or mortality . Time to surgery was insignificantly reduced from 27.4 to 21.9 hours ( P = .27 ) and surgery within 48 hours increased from 86 % to 96 % ( P = .15 ) . Discussion : The OHC has improved efficiency of hip fracture management as judged by significant reductions in LOS with a trend toward reduced TTS at our institution . Conclusion : Orthopedic-hospitalist comanagement may represent an effective strategy to improve hip fracture management in the setting of a rapidly exp and ing patient population In a prospect i ve trial of 278 patients aged over 65 years , treatment of displaced subcapital fractures was r and omly allocated to closed reduction and internal fixation with a sliding compression screwplate , Moore hemiarthroplasty , or total hip treatment with a Howse semicaptive prosthesis . One year after operation there was little difference between the three groups in mortality ( 25 per cent ) or general complications . The revision rate within the first year was highest for internal fixation ( 25 per cent ) , but many of the replacements also required a further anaesthetic for reduction of a dislocation ( Moore , 11 per cent ; Howse 12.5 per cent ) . Total hip replacement result ed in the least pain and most mobility at 1 year , while hemiarthroplasty was worst in these respects . We conclude that internal fixation and particularly primary total hip replacement should be given serious consideration in the management of the elderly patient with a displaced subcapital fracture Summary Guidelines suggest identification of women at fracture risk by bone density measurement and subsequently pharmacotherapy . However , most women who sustain a hip fracture do not have osteoporosis in terms of bone density . The present non-pharmacological intervention among elderly women unselected for osteoporosis reduced hip fracture risk by 55 % providing an alternative approach to fracture prevention . Introduction Hip fractures are expensive for society and cause disability for those who sustain them . We studied whether a multifactorial non-pharmacological prevention program reduces hip fracture risk in elderly women . Methods A controlled trial concerning 60- to 70-year-old community-dwelling Finnish women was undertaken . A r and om sample was drawn from the Population Information System and assigned into the intervention group ( IG ) and control group ( CG ) . Of the 2,547 women who were invited to the IG , 1,004 ( 39 % ) and of the 2,120 invited to the CG , 1,174 ( 55 % ) participated . The IG participated in a fracture prevention program for 1 week at a rehabilitation center followed by review days twice . The CG received no intervention . During the 10-year follow-up , both groups participated in survey question naire by mail . Outcome of interest was occurrence of hip fractures and changes in bone – health-related lifestyle . Results During the follow-up , 12 ( 1.2 % ) women in the IG and 29 ( 2.5 % ) in the CG sustained a hip fracture ( P = 0.039 ) . The determinants of hip fractures by stepwise logistic regression were baseline smoking ( odds ratio ( OR ) 4.32 ( 95 % confidence interval [ CI ] 2.14–8.71 ) , age OR 1.15/year ( 95 % CI 1.03–1.28 ) , fall history OR 2.7 ( 95 % CI 1.24–5.9 ) , stroke history OR 2.99 ( 95 % CI 1.19–7.54 ) and participating in this program OR 0.45 ( 95 % CI 0.22–0.93 ) . Starting vitamin D and calcium supplement use was more common in the IG compared with the CG . Conclusions The results suggest that this non-pharmacological fracture prevention program may reduce the risk of hip fractures in elderly Finnish women BACKGROUND Hip fracture is a condition with high mortality and morbidity in elderly frail patients . Intraoperative fluid optimization may be associated with benefit in this population . We investigated whether intraoperative fluid management using pulse-contour analysis cardiac monitoring , compared with st and ard care in patients undergoing spinal anaesthesia , would provide benefits in terms of reduced time until medically fit for discharge and postoperative complications . METHODS Patients undergoing surgical repair of fractured neck of femur , aged > 60 yr , receiving spinal anaesthesia were enrolled in this single-centre , blinded , r and omized , parallel group trial . Patients were allocated to either anaesthetist-directed fluid therapy or a pulse-contour-guided fluid optimization strategy using colloid ( Gelofusine ) boluses to optimize stroke volume . The primary outcome was time until medically fit for discharge . Secondary outcomes included postoperative complications , mobility , and mortality . We up date d a systematic review to include relevant trials to 2014 . RESULTS We recruited 130 patients .  Time until medically fit for discharge was similar in both groups , mean [ 95 % confidence interval ( CI ) ] 12.2 ( 11.1 - 13.5 ) vs 13.1 ( 11.9 - 14.5 ) days ( P=0.31 ) , as was total length of stay 14.2 ( 12.9 - 15.8 ) vs 15.3 ( 13.8 - 17.2 ) days ( P=0.32 ) . There were no significant differences in complications , function , or mortality . An up date d meta- analysis ( four studies , 355 patients ) found non-significant reduction in early mortality [ relative risk 0.66 ( 0.24 - 1.79 ) ] and in-hospital complications [ relative risk 0.80 ( 0.61 - 1.05 ) ] . CONCLUSIONS Goal -directed fluid therapy during hip fracture repair under spinal anaesthesia does not result in a significant reduction in length of stay or postoperative complications . There is insufficient evidence to either support or discount its routine use . CLINICAL TRIAL REGISTRATION IS RCT N88284896 The outcome of patients with a displaced intracapsular femoral neck fracture treated non-operatively  was assessed at 1 year and compared with patients  managed operatively over the same time period . Data were collected prospect ively for 102 consecutive patients . 80 patients underwent hemiarthroplasty and 22 were managed non-operatively .  Patients were managed non-operatively if they were felt to have an unacceptably high risk of death within the perioperative period despite medical optimisation . Non-operative management entailed active early mobilisation without bed rest or traction . Patients managed non-operatively had a greater 30-day mortality compared with operatively managed patients . Deaths were due to pre-existing medical conditions or events , which had occurred at the time of hip fracture . No patient in the non-operative treatment group developed pneumonia , pressure sores or thrombo-embolic events . Patients treated non-operatively , who survived 30 days after fracture , had a mortality rate over the following year comparable with those who had undergone surgery . At 1 year , all non-operatively managed patients were able to transfer without pain and 6 of the 11 surviving patients were able to mobilise with walking aids . At 1 year , the majority of surviving non-operatively managed patients were living in their own homes . Surgical intervention is the treatment of choice for the majority of elderly patients with a displaced intracapsular femoral neck fracture . However , in patients with life-threatening medical co-morbidity , non-operative treatment with early mobilisation can yield acceptable results Background The treatment and management of hip fracture poses a great challenge for clinicians in osteology and surgery . The aim of this study is to compare the clinical effectiveness of the percutaneous compression plate ( PCCP ) versus proximal femoral nail anti-rotation ( PFNA ) in the treatment of intertrochanteric fractures in elderly patients . Methods A prospect i ve r and omized study was carried out from January 2008 to October 2011 involving 90 elderly patients with intertrochanteric fractures ( 90 hips ) who underwent minimally invasive surgery using the PCCP or PFNA .  Evaluation variables , including operation time , intra- and perioperative blood loss , duration of hospital stay , incidence of postoperative complications , and final clinical outcomes by the end of follow-up , were used to compare the benefits of these two implants . Results Among 90 subjects , 45 received PCCPs and 45 received PFNAs . The baseline characteristics of the two groups were comparable . The median follow-up time was 16.9 months ( 12–24 months ) . In the PCCP group , the mean operative time was 53 min ( 40–75 min ) , and the mean intra- and perioperative blood losses were 100.7 ml ( 60–150 ml ) and 916 ml ( 433–1339 ml ) , respectively , which were significantly lower than those in the PFNA group . Nevertheless , there was no statistical difference in the incidence of postoperative complications and final clinical outcomes including pain complaints , range of motion of the hip , postoperative hip function at 12 months , and the recovery of walking ability to pre-injury status between these two implants . Conclusions Overall , the PCCP and PFNA appear to have similar clinical effects in treating elderly patients with intertrochanteric fractures , although the PCCP provided shorter operation times and less blood loss than PFNA . Both implants discussed were demonstrated to be ideal for the treatment of femoral intertrochanteric fractures in elderly patients OBJECTIVES To ascertain the most common causes of delirium , to establish the initiation and timing of delirium , and to determine the duration of delirium in patients with hip fracture . METHODS Five hundred seventy-one ( 88 % ) of 650 patients with hip fracture admitted to 4 New York City hospitals were prospect ively interviewed on a daily basis , 5 days a week , with the Confusion Assessment Method for the presence of delirium . The patients were enrolled within 48 hours of admission . Their medical charts and the data collected by the study staff were review ed and summarized . Two of us ( R.S.M. and A.L.S. ) review ed the case summaries independently and assigned a cause based on a previously developed classification system , estimated the onset of the delirious episode , and determined whether the delirium had cleared , improved , or persisted at discharge . Subsequently , discrepancies in cause , timing of initiation , and mental status on discharge between the 2 physicians review ers were discussed until consensus was reached . RESULTS The prevalence of delirium was 9.5 % ( 54/ 571 ; 95 % confidence interval , 7.0 - 11.9 ) . Seven percent of episodes were assigned a definite cause , 20 % a probable cause , 11 % a possible cause , and 61 % were attributable to 1 or more comorbid conditions . Twenty-eight ( 53 % ) of 54 subjects developed delirium after surgery . The delirium had cleared or improved in 40 ( 74 % ) of 54 subjects at the time of discharge . CONCLUSIONS Delirium in patients with hip fracture appears to be a different syndrome from that observed in patients who are otherwise medically ill ; it also appears to follow a different clinical course . These results have important implication s for the management of delirium in patients with hip fracture Background Approximately 70,000 patients /year undergo surgery for repair of a fractured hip in the United Kingdom . This is associated with 30-day mortality of 9 % and survivors have a considerable length of acute hospital stay postoperatively ( median 26 days ) . Use of oesophageal Doppler monitoring to guide intra-operative fluid administration in hip fracture repair has previously been associated with a reduction in hospital stay of 4 - 5 days . Most hip fracture surgery is now performed under spinal anaesthesia . Oesophageal Doppler monitoring may be unreliable in the presence of spinal anaesthesia and most patients would not tolerate the probes . An alternative method of guiding fluid administration ( minimally-invasive arterial pulse contour analysis ) has been shown to reduce length of stay in high-risk surgical patients but has never been studied in hip fracture surgery . Methods Single-centre r and omised controlled parallel group trial . R and omisation by website using computer generated concealed tables . Setting : University hospital in UK . Participants : 128 patients with acute primary hip fracture listed for operative repair under spinal anaesthesia and aged > 65 years . Intervention : Stroke volume guided intra-operative fluid management . Continuous measurement of SV recorded by a calibrated cardiac output monitor ( LiDCOplus ) . Maintenance fluid and 250 ml colloid boluses given to achieve sustained 10 % increases in stroke volume . Control group : fluid administration at the responsible ( blinded ) anaesthetist 's discretion . The intervention terminates at the end of the surgical procedure and post-operative fluid management is at the responsible anaesthetist 's discretion . Primary outcome : length of acute hospital stay is determined by a blinded team of clinicians . Secondary outcomes include number of complications and total cost of care . Funding NIHR/RfPB : PB-PG-0407 - 13073.Trial registration numberTrial registration : Current Controlled Trials IS RCT N88284896 BACKGROUND People with cognitive impairment and dementia have a poor outcome after a hip fracture surgery , about 30 - 50 % of all those who sustain a hip fracture have dementia . Therefore the aim was to investigate whether a multidisciplinary postoperative intervention program could reduce postoperative complications and improve functional recovery among people with dementia . METHODS A r and omized controlled trial with subgroup analyses among patients with dementia . Sixty-four patients with femoral neck fracture , aged ≥70 years at Umeå University Hospital , Sweden . The intervention consisted of staff education , individualized care planning and rehabilitation , active prevention , detection and treatment of postoperative complications , especially delirium . The staff worked in teams to apply comprehensive geriatric assessment , management and rehabilitation , including a follow-up at 4 months postoperatively . The control group followed conventional postoperative routines . RESULTS There were fewer postoperative complications in the intervention group such as urinary tract infections , p=0.001 ; nutritional problems , p=0.025 ; postoperative delirium , p=0.002 ; falls , p=0.006 . At 4 months a larger proportion in the intervention group had regained their previous independent indoor walking ability performance , p=0.005 . At 12 months a larger proportion in the intervention group had regained the activities of daily living ( ADL ) performance level they had before the fracture , p=0.027 . CONCLUSION This study demonstrates that patients with dementia who suffer a hip fracture can benefit from multidisciplinary geriatric assessment and rehabilitation and should not be excluded from rehabilitation programs OBJECTIVE To determine rheumatologists ' preferences in the medical management of osteoarthritis ( OA ) of the hip and knee , and examine possible variations in these preferences . METHODS A stratified r and om sample of 1,001 rheumatologists in community-based practice in the United States was surveyed by mail . RESULTS Responses were obtained form 594 subjects ( 529 white , 499 male , mean + /- SD age 47.4 + /- 8.1 years ) . Over 80 % used acetaminophen or nonaspirin , nonsteroidal antiinflammatory drugs ( NSAIDs ) either always or frequently for the management of OA of the hip and knee . A majority used the following nonpharmacologic methods either always or frequently : weight loss , cane or crutch , physical and /or occupational therapy referral  , and  exercise .  Variation in practice preferences was noted by age ( < 47 versus > or = 47 years ) , sex , board certification in rheumatology , and number of patients seen per month . Respondents felt that severe pain and limitation of function were the most important factors in recommending total join arthroplasty for patients . CONCLUSION These data demonstrate that practicing rheumatologists most often use either acetaminophen and /or NSAIDs in combination with nonpharmacologic methods in the medical management of OA of the hip and knee . The existence of variation in practice preferences has policy implication Objective To compare the analgesic benefit of preoperative skin traction with the placement of a pillow under the injured extremity in patients with hip fractures . Design Prospect i ve , r and omized clinical study . Setting University-affiliated teaching institution . Patients and Participants One hundred consecutive patients with hip fractures admitted to the authors ' institution who met inclusion criteria were enrolled . Fifty-five patients had femoral neck fractures , and forty-five patients had intertrochanteric fractures . The average patient age was seventy-eight years . Intervention All patients were preoperatively r and omized into two intervention groups . One group underwent placement of five pounds of skin traction on the injured extremity , whereas the second underwent placement of a pillow under the injured extremity . Fifty patients were enrolled in each intervention group . Results With respect to immediate postintervention pain levels , patients treated with a pillow showed a trend toward better pain relief , as compared with patients treated with skin traction ; however , this was not statistically significant . On the morning after admission , patients treated with a pillow had a statistically significant greater reduction in pain ( p = 0.04 ) . These patients also requested a statistically significant lower amount of pain medication ( p < 0.01 ) . Conclusions The authors think that preoperative skin traction in patients with hip fractures does not provide significant pain relief , as compared with pillow placement under the injured extremity , and thus should not be routinely performed in this patient population for analgesia The National Institutes of Health 's consensus conference ( 1 ) defined osteoporosis as a skeletal disorder characterized by compromised bone strength predisposing to an increased risk for fracture . Bone strength reflects the integration of two main features : bone density and bone quality .Bone quality refers to architecture , turnover , damage accumulation ( e.g. , microfractures ) , and mineralization . Although osteoporosis can affect any bone , the hip , spine , and wrist are most likely to be affected . Osteoporosis affects an estimated 44 million Americans or 55 % of people 50 years of age or older . Another 34 million Americans are estimated to have low bone mass , meaning that they are at an increased risk for osteoporosis . Osteoporosis can be diagnosed by the occurrence of fragility fracture . In patients without fragility fracture , osteoporosis is often diagnosed by low bone density .  Dual x-ray absorptiometry ( DXA ) is the current gold st and ard test for diagnosing osteoporosis in people without an osteoporotic fracture .  Dual x-ray absorptiometry results are scored as st and ard deviations ( SDs ) from a young healthy norm ( usually female ) and reported as T-scores . For example , a T-score of 2 indicates a bone mineral density that is 2 SDs below the comparative norm . The international reference st and ard for the description of osteoporosis in postmenopausal women and in men age 50 years or older is a femoral neck bone mineral density of 2.5 SD or more below the young female adult mean ( 2 ) . Low bone density , as measured by DXA , is an imperfect predictor of fracture risk , identifying fewer than half the people who go on to have an osteoporotic fracture . Screening guidelines for women are well established ( 3 ) , and the American College of Physicians ( ACP ) recently published guidelines on screening for men ( 4 ) . This guideline presents the available evidence on various pharmacologic treatments to prevent fractures in men and women with low bone density or osteoporosis . Medications used to treat osteoporosis may affect different parts of the skeletal system differently , and efficacy for vertebral fractures does not necessarily imply efficacy for nonvertebral fractures . The target audience for this guideline is all clinicians and the target patient population is all adult men and women with low bone density or osteoporosis . These recommendations are based on the systematic evidence review by MacLean and colleagues ( 5 ) and the Agency for Healthcare Research and Quality sponsored Southern California Evidence -Based Practice Center evidence report ( 6 ) . The drugs currently approved for prevention of osteoporosis include alendronate , ib and ronate , risedronate , zoledronic acid , estrogen , and raloxifene . The drugs currently approved for treatment of osteoporosis include alendronate , ib and ronate , risedronate , calcitonin , teriparatide , zoledronic acid ( in postmenopausal women ) , and raloxifene . Testosterone , pamidronate , and etidronate are not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Methods The literature search done by MacLean and colleagues for the systematic review ( 5 ) included studies from MEDLINE ( 1966 to December 2006 ) , the ACP Journal Club data base , the Cochrane Central Register of Controlled Trials ( no date limits ) , the Cochrane Data base of Systematic Review s ( no date limits ) , Web sites of the United Kingdom National Institute of Health and Clinical Excellence ( no date limits ) , and the United Kingdom Health Technology Assessment Program ( January 1998 to December 2006 ) . The review ers limited their search to English- language publications and human studies . They derived evidence for comparative benefits of various treatments exclusively from r and omized , controlled trials , whereas they included evidence from other types of studies for short- and long-term harms . Two physicians independently abstract ed data about study population s , interventions , follow-up , and outcome ascertainment by using a structured form . For each group within a r and omized trial , a statistician extracted the sample size and number of persons reporting fractures . Two review ers , under the supervision of the statistician , independently abstract ed information about adverse events . The statistician or the principal investigator resolved disagreements . This guideline is based on an evaluation of 76 r and omized , controlled trials , 4 of which were identified in the up date d search , and 24 meta-analyses that were included in the efficacy analyses . The analyses of adverse events included 491 articles , representing 417 r and omized trials , 25 other controlled clinical trials , 11 open-label trials , 31 large observational studies , and 9 case reports of osteonecrosis among bisphosphonate users . MacLean and colleagues ' background article ( 5 ) includes details about the methods used for the systematic evidence review . The ACP rates the evidence and recommendations by using the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) system with minor modifications ( Table 1 ) . In addition , the evidence review ers used predefined criteria to assess the quality of systematic review s and r and omized trials , based on internal and external validity assessment s detailed in the Quality of Reporting of Meta-Analyses ( QUOROM ) statement ( 7 ) . Table 1 . The American College of Physicians ' Guideline Grading System The objective of this guideline is to synthesize the evidence for the following questions : What are the comparative benefits in fracture reduction among and also within the following treatments for low bone density :  bisphosphonates , specifically alendronate , risedronate , etidronate , ib and ronate , pamidronate , and zoledronic acid ; calcitonin ; estrogen for women ; teriparatide ; selective estrogen receptor modulators ( SERMs ) , specifically raloxifene and tamoxifen ; testosterone for men ; vitamins and minerals , specifically vitamin D and calcium ; and the combination of calcium plus vitamin D ? How does fracture reduction result ing from treatments vary among individuals with different risks for fracture as determined by bone mineral density ( borderline , low , or severe ) , previous fractures ( prevention vs. treatment ) , age , sex , glucocorticoid use , and other factors ( such as community-dwelling vs. institutionalized or vitamin Ddeficient vs. not ) ? What are the short- and long-term harms ( adverse effects ) of these therapies , and do these vary by specific sub population s ? Comparative Benefits of Drugs versus Placebo in Fracture Reduction Evidence from 24 meta-analyses ( 830 ) and 35 additional r and omized trials published after the meta-analyses ( 3165 ) described the effect of 9 of the 14 agents ( alendronate , etidronate , risedronate , calcitonin , estrogen , teriparatide , raloxifene , calcium , and vitamin D ) on fracture incidence . For 4 agents ( ib and ronate , pamidronate , zoledronic acid , and tamoxifen ) , the review ers found no meta-analyses and instead gathered the evidence from 14 r and omized trials ( 6679 ) . No studies were found that reported fracture rates for testosterone . Three r and omized trials ( 35 , 80 , 81 ) and 1 meta- analysis ( 82 ) evaluated the combination of calcium plus vitamin D  on fractures .  Bisphosphonates Good- quality evidence showed that alendronate , etidronate , ib and ronate , and risedronate prevent vertebral fractures . In addition , evidence from good- quality studies demonstrated that both alendronate and risedronate prevent nonvertebral and hip fractures . Two large r and omized trials showed that zoledronic acid prevents vertebral and nonvertebral fractures in high-risk population s and reduces the risk for hip fracture ( 67 , 74 ) . Ib and ronate has not been shown to reduce nonvertebral fractures ( 68 ) . Of the 6 fairly small trials that looked at vertebral fractures , 1 demonstrated a statistically significant reduction in fractures with pamidronate relative to placebo ( 0.14 [ 95 % CI , 0.03 to 0.72 ] ) ( 73 ) . However , after these data were pooled , the pooled risk estimate for fractures for pamidronate relative to placebo was not significant ( 0.52 [ CI , 0.21 to 1.24 ] ) ( 6 ) . Calcitonin Fair- quality evidence shows that calcitonin reduces vertebral fractures ( 83 , 84 ) . Good- quality evidence indicates that calcitonin does not reduce nonvertebral fractures ( 13 , 16 ) . Estrogen Good- quality evidence shows that estrogen reduces the incidence of vertebral ( 29 , 85 ) , nonvertebral ( 86 ) , and hip fractures ( 85 ) . Teriparatide Good- quality evidence shows that teriparatide prevents vertebral fractures . The evidence related to teriparatide preventing nonvertebral fractures is mixed ; 1 large r and omized trial showed a reduction in nonvertebral fractures ( 34 ) but 2 small trials did not ( 87 , 88 ) . SERMs Good- quality evidence shows that raloxifene prevents vertebral fractures , but that tamoxifen has no effect on vertebral fractures ( 8991 ) . In addition , both raloxifene and tamoxifen had no effect on hip fractures ( 91 ) . Tamoxifen is not approved by the U.S. Food and Drug Administration for the treatment or prevention of osteoporosis . Testosterone No studies reported fracture rates for testosterone . Calcium and Vitamin D In the studies evaluated by MacLean and colleagues ( 5 ) , the evidence for the effect of calcium alone on reduction of fractures is complex . Most studies of pharmacologic agents for osteoporosis include calcium and vitamin D as part of the treatment regimen . Evidence from 1 meta- analysis ( 27 ) and several r and omized trials ( 35 , 48 , 51 , 92 ) showed no significant difference between calcium and placebo in preventing vertebral , nonvertebral , and hip fractures in postmenopausal women . However , nonadherence to therapy may influence this result , and 1 trial with a prespecified analysis of adherent patients found a reduction in fracture risk ( 48 ) . A recent meta- analysis ( 82 ) concluded that the relative risk ( RR ) for fracture with calcium alone was 0.90 ( CI , 0.80 to 1.00 ) , but it did not include a modestly large trial with negative results ( 35 ) . MacLean and colleagues ( 5 ) AIM To report a study of the effects of protein-energy malnutrition on the functional recovery of older people with hip fracture who participated in an interdisciplinary intervention . BACKGROUND It is not clear whether protein-energy malnutrition is associated with worse functional outcomes or it affects the interdisciplinary intervention program on the functional recovery of older people with hip fracture . DESIGN A r and omized experimental design . METHODS Data were collected between 2002 - 2006 from older people with hip fracture ( N = 162 ) in Taiwan . The generalized estimating equations approach was used to evaluate the effect of malnutrition on the functional recovery of older people with hip fracture . RESULTS The majority of older patients with hip fracture were malnourished ( 48/80 , 60 % in the experimental group vs. 55/82 , 67 % in the control group ) prior to hospital discharge . The results of the generalized estimating equations analysis demonstrated that subjects suffering from protein-energy malnutrition prior to hospital discharge appeared to have significantly worse performance trajectories for their activities of daily living , instrumental activities of daily living , and recovery of walking ability compared with those without protein-energy malnutrition . In addition , it was found that the intervention is more effective on the performance of activities of daily living and recovery of walking ability in malnourished patients than in non-malnourished patients . CONCLUSION Healthcare providers should develop a nutritional assessment /management system in their interdisciplinary intervention program to improve the functional recovery of older people with hip fracture Aims : This study was undertaken to estimate the effect of hip protectors on the incidence of hip fracture when introduced into nursing homes as a regular part of the healthcare for all residents . Methods : A pre-test/test design was used . The pre-intervention period lasted 18 months from May 1996 . The intervention period lasted 18 months from May 1998 . During the intervention period all residents ( 965 beds ) in nursing homes in two municipalities in Norway were offered free use of hip protectors . The project manager provided motivational activities in the nursing homes during the whole period , aim ed at increasing the participation rate . Results : The intervention period showed a 39 % reduction in the hip fracture incidence when compared with the pre-intervention period ( p=0.003 ) . The percentage of daily users of the protector varied from 35 % during the first months to 22 % at the end of the period . Among the 61 persons who suffered a hip fracture 31 were registered as daily users . Fourteen of the 31 users were not wearing the protector when the hip fracture occurred , while five of the 31 had the protector on their knees . Twelve of the 31 suffered a hip fracture while properly wearing the protector . Conclusions : This non-r and omized study showed that hip protectors introduced to all residents in nursing homes considerably reduced the incidence of hip fracture . It may be possible to achieve higher compliance and a further reduction in the incidence of hip fractures if the producers of hip protectors increase the comfort of the protector without reducing its effect . In addition , it is important that health workers encourage more individuals at high risk to use the protector Background : Pain is 1 of the most common symptoms that a cancer patient would experience . A significant barrier to positive pain management is patients ’ misconceptions regarding analgesics and inadequate use of nonpharmacological strategies as pain relief . Objective : The purpose of this study was to investigate the effectiveness of a pain management program ( PMP ) on pain intensity , use of PRN drugs  and  nonpharmacological strategies  as pain relief , and barriers to managing pain in cancer patients . Methods : The study was conducted in the palliative care and hospice ward of a public hospital in Hong Kong . Patients were r and omized to either an experimental group ( receiving the PMP ) or a control group ( routine care ) . There were 38 hospitalized patients , with 20 ( 13 males and 7 females ) in the experimental group and 18 ( 11 males and 7 females ) in the control group ; mean age was 61.95 years ( experimental group ) to 63.94 years ( control group ) . Results : Upon the completion of PMP , pain scores were significantly reduced in both groups , yet patients in the experimental group showed a significant increase in the use of PRN analgesics and nonpharmacological strategies to relieve pain ( P < .05 ) and significantly reduce barriers to managing their cancer pain ( P < .05 ) compared with the control group . Conclusion : Cancer patients should be empowered with pain management education to gain knowledge and correct misconceptions in managing their cancer pain . Implication s for Practice : Integration of the PMP into routine clinical work may help to improve the st and ard of care for cancer patients . It is recommended to provide pain management education to all cancer patients The rehabilitation of elderly patients after hip fractures is important : we report a prospect i ve study which compares supported home rehabilitation with management in hospital in two similar groups of patients . Our results show that early discharge from  hospital  and  home rehabilitation  produces substantial savings in bed days , and also provides quicker and more effective recovery OBJECTIVES To evaluate the effect of a psychiatric intervention in treating depression ( treatment study ) and the effect of a psychological treatment in preventing depression ( prevention study ) after hip fracture in older people . DESIGN Two linked r and omized , controlled trials . SETTING Orthopedic units in Manchester , Engl and . PARTICIPANTS Two hundred ninety-three older people who had undergone surgery for a fractured hip : 121 in the treatment study and 172 in the prevention study . MEASUREMENTS The Geriatric Depression Scale and Hospital Anxiety and Depression Scale for mood , functional tests for mobility and pain measures . RESULTS There was a slight reduction in depressive symptoms in the active arm of the treatment study . In the prevention study , there was no significant difference in incident depression between the psychological intervention and treatment as usual . There were no differences in the functional and pain outcomes . CONCLUSION The results from these two r and omized , controlled trials show that , after hip fracture surgery , no statistically significant benefits can be achieved from a psychiatric intervention in people who are depressed or a psychological intervention to prevent the onset of depression INTRODUCTION This r and omised study evaluates the effect of intensive physical therapy on the duration of rehabilitation following hip fracture . METHODS Eighty-eight patients transferred for rehabilitation after surgical treatment for hip fracture were included in the trial . Forty-four patients were r and omised to physical therapy 3.6 hours ( median ) a week , while the 44 control patients received physical therapy 1.9 hours a week . Outcome was defined as duration of physical rehabilitation until the patient was able to ( 1 ) walk 50 metres in less than 2 minutes , ( 2 ) manage stair climbing to the first floor , ( 3 ) manage sit-to-st and transfer , ( 4 ) move in and out of bed , ( 5 ) manage bathing , dressing and lavatory visits . RESULTS In the group r and omised to intensive physical therapy 24 patients withdrew after 15 days while 13 patients withdrew from the control group after 22 days ( median values ) . Early withdrawal was due to orthopaedic complications , general weakness and poor co-operation . No difference between the two groups was demonstrated in the duration of physical rehabilitation by a per protocol analysis of the patients who completed the trial . DISCUSSION The considerable drop-out rate suggests that intensive physical therapy may be of limited value when attempting to reduce the duration of rehabilitation following hip fracture . An altered objective including enhanced out-patient rehabilitation may be necessary in order to reduce the length of hospital stay after hip fracture The purpose of this study was to evaluate adherence to home-based exercise interventions among older women post hip fracture that were r and omized to one of three exercise intervention groups or a routine care group .  A total of 157 female hip fracture patients provided data for the intervention analysis . Factors evaluated baseline , 2 , 6 , and 12 months post hip fracture included demographic variables , adherence to treatment visits , self-efficacy , outcome expectations , stage of change for exercise , social support for exercise , mood , health status , pain , and fear of falling . The hypothesized model tested the direct and indirect impact of all study variables on adherence to exercise intervention sessions . Different factors appeared to influence adherence to visits across the recovery trajectory Description This guideline up date s the 2008 American College of Physicians ( ACP ) recommendations on treatment of low bone density and osteoporosis to prevent fractures in men and women . This guideline is endorsed by the American Academy of Family Physicians . Methods The ACP Clinical Guidelines Committee based these recommendations on a systematic review of r and omized controlled trials ; systematic review s ; large observational studies ( for adverse events ) ; and case reports ( for rare events ) that were published between 2 January 2005 and 3 June 2011 . The review was up date d to July 2016 by using a machine-learning method , and a limited up date to October 2016 was done . Clinical outcomes evaluated were fractures and adverse events . This guideline focuses on the comparative benefits and risks of short- and long-term pharmacologic treatments for low bone density , including pharmaceutical prescriptions , calcium , vitamin D , and estrogen . Evidence was grade d according to the GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) system . Target Audience and Patient Population The target audience for this guideline includes all clinicians . The target patient population includes men and women with low bone density and osteoporosis . Recommendation 1 ACP recommends that clinicians offer pharmacologic treatment with alendronate , risedronate , zoledronic acid , or denosumab to reduce the risk for hip and vertebral fractures in women who have known osteoporosis . ( Grade : strong recommendation ; high- quality evidence ) . Recommendation 2 ACP recommends that clinicians treat osteoporotic women with pharmacologic therapy for 5 years . ( Grade : weak recommendation ; low- quality evidence ) . Recommendation 3 ACP recommends that clinicians offer pharmacologic treatment with bisphosphonates to reduce the risk for vertebral fracture in men who have clinical ly recognized osteoporosis . ( Grade : weak recommendation ; low- quality evidence ) . Recommendation 4 ACP recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women . ( Grade : weak recommendation ; low- quality evidence ) . Recommendation 5 ACP recommends against using menopausal estrogen therapy or menopausal estrogen plus progestogen therapy or raloxifene for the treatment of osteoporosis in women . ( Grade : strong recommendation ; moderate- quality evidence ) . Recommendation 6 ACP recommends that clinicians should make the decision whether to treat osteopenic women 65 years of age or older who are at a high risk for fracture based on a discussion of patient preferences , fracture risk profile , and benefits , harms , and costs of medications . ( Grade : weak recommendation ; low- quality evidence ) BACKGROUND Treatment acceptance by patients is influenced by the way treatment effects are presented . Presentation of benefits using relative risk increases treatment acceptance compared to the use of absolute risk . It is not known whether this effect is modified by prior presentation of a patient 's individualised risk estimate or how presentation of treatment harms by relative or absolute risk affects acceptance . AIM To compare acceptance of a hypothetical treatment to prevent hip fracture after presentation of the treatment 's benefit in relative or absolute terms in the context of a personal fracture risk estimate , and to reassess acceptance following subsequent presentation of harm in relative or absolute terms . DESIGN AND SETTING R and omised controlled trial of patients recruited from 10 GPs ' lists in Christchurch , New Zeal and . METHOD Women aged ≥ 50 years were invited to participate . Participants were given a personal 10-year hip fracture risk estimate and r and omised to receive information on a hypothetical treatment 's benefit and harm in relative or absolute terms . RESULTS Of the 1140 women invited to participate 393 ( 34 % ) took part .  Treatment acceptance was greater following presentation of benefit using absolute terms than relative terms after adjustment forage , education , previous osteoporosis diagnosis , and self-reported risk ( OR 1.73 , 95 % confidence interval [ CI ] = 1.10 to 2.73 , P = 0.018 ) . Presentation of the treatment 's harmful effect in relative terms led to a greater proportion of participants declining treatment than did presentation in absolute terms ( OR 4.89 , 95 % CI = 2.3 to 11.0 , P<0.001 ) . CONCLUSION Presentation of treatment benefit and harm using absolute risk estimates led to greater treatment acceptance than presentation of the same information in relative terms BACKGROUND Little evidence is available on the longer-term effects ( beyond 12 months ) of intervention models consisting of hip fracture-specific care in conjunction with management of malnutrition , depression , and falls . OBJECTIVE To compare the relative effects of an interdisciplinary care , and a comprehensive care programme with those of usual care for elderly patients with a hip fracture on self-care ability , health care use , and mortality .  DESIGN R and omised experimental trial . SETTING A 3000-bed medical centre in northern Taiwan . PARTICIPANTS Patients with hip fracture aged 60 years or older ( N=299 ) . METHOD Patients were r and omly assigned to three groups : comprehensive care ( n=99 ) , interdisciplinary care ( n=101 ) , and usual care ( control ) ( n=99 ) . Usual care entailed only one or two in-hospital rehabilitation sessions . Interdisciplinary care included not only hospital rehabilitation , but also geriatric consultation , discharge planning , and 4-month in-home rehabilitation . Building upon interdisciplinary care , comprehensive care extended in-home rehabilitation to 12 months and added management of malnutrition and depressive symptoms , and fall prevention . Patients ' self-care ability was measured by activities of daily living and instrumental activities of daily living using the Chinese Barthel Index and Chinese version Instrumental Activities of Daily Living scale , respectively . Outcomes were assessed before discharge , and 1 , 3 , 6 , 12 , 18 , 24 months following hip fracture . Hierarchical linear models were used to analyse health outcomes and health care utilisation , including emergency department visit and hospital re-admission . RESULTS The comprehensive care group had better performance trajectories for both measures of activities of daily living and fewer emergency department visits than the usual care group , but no difference in hospital readmissions . The interdisciplinary care and usual care groups did not differ in trajectories of self-care ability and service utilisation . The three groups did not differ in mortality during the 2-year follow-up . CONCLUSION Comprehensive care , with enhanced rehabilitation , management of malnutrition and depressive symptoms , and fall prevention , improved self-care ability and decreased emergency department visits for elders up to 2 years after hip-fracture surgery , above and beyond the effects of usual care and interdisciplinary care INTRODUCTION The usefulness of peripheral femoral nerve block for pain management after hip fracture has been established . This prospect i ve and r and omised study compared the analgesia effect of a continuous femoral nerve block ( CF ) versus two conventional analgesia procedures  after hip fracture . PATIENTS AND METHODS Patients . ( n=62 ) scheduled for surgery under spinal anaesthesia were prospect ively included . After surgery , analgesia ( 48 hours ) was r and omised : group FC ( femoral catheter , anterior paravascular approach , initial bolus followed by continuous infusion of ropivacaine 0.2 % ) , group P ( iv 2 g propacetamol/6 hours ) , group M ( sc morphine , 0.05 mg/kg per 4 hour ) . Intravenous morphine titration was performed , followed by subcutaneous ( sc ) morphine every 4 hours according to the VAS score . The primary end-point was the  morphine requirements . Secondary end-points were VAS score , side effects , and mortality . RESULTS Demographic data and surgical procedures were similar between groups . After morphine titration , the VAS pain score did not differ between groups . All patients in-group M received additional morphine .  Morphine mean consumption was increased in CF group : 26 mg ( 5 - 42 ) versus P : 8 mg ( 3 - 12 ) ( p=0.0001 ) or M : 19 mg ( 8 - 33 ) ( p<0.006 ) while constipation was decreased in P group vs CF . Percentage of patients requiring no morphine  was similar between P ( n=6 ; 28 % ) and CF ( n=6 ; 28 % ) and greater than M ( n=0 ; 0 % ) . Hospital discharge , cardiovascular or pulmonary complications and mortality after 6 months showed no statistical difference . CONCLUSION Continuous femoral nerve block provided limited pain relief after hip fracture did not reduced side effects and induced an expensive cost Background The course and outcomes of hip fracture patients are often complicated by the presence of dementia and delirium , referred to as cognitive impairment ( CI ) , which limits access to in-patient rehabilitation . In response to this concern , members of our team developed and piloted an in-patient rehabilitation model of care ( Patient-Centred Rehabilitation Model ; PCRM ) targeting patients with hip fracture and CI ( PCRM-CI ) . We are now conducting a 3-year study comparing an inpatient rehabilitation model of care for  community dwelling individuals with hip fracture and CI ( PCRM-CI ) to usual care to determine whether it results in improved mobility at the time of discharge from inpatient rehabilitation . Methods / Design A non-equivalent pre-post design is being used to evaluate the PCRM-CI compared to usual care .  All community dwelling ( private home or retirement home ) patients following a hip fracture are eligible to participate . Recruitment of both cohorts is taking place at two facilities . Target accrual is 70 hip fracture patients in the PCRM-CI cohort and 70 patients in the usual care cohort . We are also recruiting 70 health care providers ( HCPs ) , who are being trained to implement the PCRM-CI , and their unit managers . Patient data are collected at baseline , discharge , and 6 months post-discharge from an inpatient rehabilitation program . Evaluations include mobility , physical function , and living arrangement . Additional outcome variables are being collected from medical records and from the patients via their proxies . Data on the prevalence and severity of dementia and delirium are being collected . Staff data are collected at baseline and one year after implementation of the model to determine change in staff knowledge and attitudes toward patients with hip fracture and CI . Bi-monthly semi-structured interviews with unit managers have been conducted to examine factors and barriers influencing the model implementation . Data collection began in 2009 and is expected to be completed in 2012 . The control cohort of 70 patients has been recruited , and 45 patients have been accrued to the intervention group to date . Discussion Evaluation of this model of care is timely given the increasing proportion of persons with cognitive impairment and hip fractures . Trial registration The study is registered at http:// clinical trials.gov , Identifier NCT01566136 OBJECTIVE To compare the efficacy of the gamma nail ( GN ) to the dynamic hip screw ( DHS ) in the management of intertrochanteric hip fractures . DESIGN R and omized , prospect i ve clinical trial with a mean follow-up of 52 weeks ( range from 11 to 82 weeks ) . SETTING A university teaching hospital . PATIENTS One hundred and one patients with 102 fractures : 49 fractures were treated with the DHS and 53 fractures were treated with the GN .  INTERVENTIONS Fracture fixation with the DHS or the GN . MAIN OUTCOME MEASURES Comparison of duration of operation , blood loss , early and late complications , functional outcome and duration of hospital stay . RESULTS There was no significant difference between the two groups with respect to intraoperative blood loss , days in hospital , time to union and eventual functional outcome . The length of the procedure and fluoroscopy time were longer for the GN group . CONCLUSIONS Both the GN and the DHS can be used effectively for the treatment of intertrochanteric fractures . In this study the DHS was associated with a lower risk of local complications and should still be considered to be the implant of choice for patients with intertrochanteric fractures OBJECTIVE to compare the effects of two different exercise programmes after hip fracture . DESIGN assessor-blinded r and omised controlled trial . SETTING hospital rehabilitation units , with continued intervention at home . SUBJECTS 160 people with surgical fixation for hip fracture transferred to inpatient rehabilitation . METHOD in addition to other rehabilitation strategies , the intervention group received a higher dose ( 60 min/day ) exercise programme conducted whilst st and ing and the control group received a lower dose exercise programme ( 30 min/day ) primarily conducted whilst seated/supine . The primary outcome measures were knee extensor muscle strength in the fractured leg and walking speed , measured at 4 and 16 weeks . RESULTS 150 participants ( 94 % of those recruited ) completed the trial . There were no differences between the groups for the two primary outcome measures . Post hoc analyses revealed increased walking speed among those in the higher dose , weight-bearing exercise group with cognitive impairment at 4 and 16 weeks . CONCLUSIONS there was no benefit ( or harm ) due to the higher dose , weight-bearing exercise programme with respect to the primary outcome measures . However , people with hip fracture and cognitive impairment gained greater benefit from the higher dose programme than from the lower dose programme OBJECTIVE We aim ed to determine whether a novel Patient Empowerment and Physician Alerting ( PEPA ) intervention would improve the proportion of seniors who were investigated and treated for osteoporosis after hip fracture . METHODS We undertook a 6-month r and omized controlled trial ( RCT ) in 48 women and men > /= 60 years old who had suffered a hip fracture and were admitted to a tertiary-care university hospital . The primary outcome measure was the proportion of participants offered one or more osteoporosis-specific ' best practice s ' measured using the Diagnosis and Management Question naire ( DMQ ) . Participant responses were vali date d in part by physician report . RESULTS In the PEPA intervention group , 19 ( 68 % ) were offered one or more components of best practice care  compared with 7 ( 35 % ) in the ' usual care ' group ( p < .05 ) . In the PEPA group , 15 ( 54 % ) ( p < .01 ) were prescribed  bisphosphonate therapy  , 8 ( 29 % ) ( p < .01 ) had a bone mineral density scan , 11 ( 39 % ) were prescribed calcium and vitamin D ( p = .32 ) , and 9 ( 32 % ) ( p < .01 ) were prescribed exercise .  In the usual care group , 0 ( 0 % ) were prescribed  bisphosphonate therapy , a  bone mineral density assessment , or exercise  and 6 ( 30 % ) were prescribed calcium and vitamin D. CONCLUSIONS This simple , inexpensive PEPA intervention result ed in far superior clinical management than did usual care in a population at high risk of future hip fracture Background : Perioperative myocardial ischaemia is an important risk factor for cardiac morbidity and mortality after noncardiac surgery . The impact of analgesic management on the incidence and severity of cardiac ischemia was studied in 77 elderly patients undergoing surgical treatment of traumatic hip fracture Advanced dementia patients may be at substantial risk for undetected or undertreated pain . To examine the treatment of pain  following hip fracture , a prospect i ve cohort study was conducted in an academic teaching hospital . Fifty-nine cognitively intact elderly patients with hip fracture and 38 patients with hip fracture and advanced dementia were assessed daily . The cognitively intact patients rated their pain on a numeric scale ranging from 0 ( none ) to 4 ( very severe ) . Analgesics prescribed and administered were recorded and compared to hip fracture patients with advanced dementia . The advanced dementia patients received one-third the amount of morphine sulfate equivalents as the cognitively intact patients . Forty-four percent of cognitively intact individuals reported severe to very severe pain preoperatively and 42 % reported similar pain postoperatively . Half the cognitively intact patients who experienced moderate to very severe pain were prescribed inadequate analgesia for their level of pain . Eighty-three percent of cognitively intact patients and 76 % of dementia patients did not receive a st and ing order for an analgesic agent . These data reveal that a majority of elderly hip fracture patients experienced undertreated pain . The fact that advanced dementia patients received one-third the amount of opioid analgesia  as compared to cognitively intact subjects-40 % of whom reported severe pain postoperatively-suggests that the majority of dementia patients were in severe pain postoperatively . This study and others suggest that directed interventions to improve pain detection and alter physician prescribing practice s in the cognitively impaired are needed The treatment algorithms for displaced fractures of the femoral neck need to be improved if we are to reduce the need for secondary surgery . We have studied 102 patients of mean age 80 years , with an acute displaced fracture of the femoral neck . They were r and omly placed into two groups , treated either by internal fixation ( IF ) with two cannulated screws or total hip replacement ( THR ) . None showed severe cognitive dysfunction , all were able to walk independently , and all lived in their own home . They were review ed at four , 12 and 24 months after surgery . Outcome measurements included hip complications , revision surgery , hip function according to Charnley and the health-related quality of life ( HRQoL ) according to EuroQol ( EQ-5D ) . The failure rate after 24 months was higher in the IF group than in the THR group with regard to hip complications ( 36 % and 4 % , respectively ; p < 0.001 ) , and the number of revision procedures ( 42 % and 4 % , p < 0.001 ) . Hip function was significantly better in the THR group at all follow-up review s regarding pain ( p < 0.005 ) , movement ( p < 0.05 except at 4 months ) and walking ( p < 0.05 ) . The reduction in HRQoL ( EQ-5D index score ) was also significantly lower in the THR group than in the IF group , comparing the pre-fracture situation with that at all follow-up review s ( p < 0.05 ) . The results of our study strongly suggest that THR provides a better outcome than IF for elderly , relatively healthy , lucid patients with a displaced fracture of the femoral neck BACKGROUND This study is a part of the r and omized controlled trial , the Trondheim Hip Fracture Trial , and it compared physical behavior and function during the first postoperative days for hip fracture patients managed with comprehensive geriatric care ( CGC ) with those managed with orthopedic care ( OC ) .  METHODS Treatment comprised CGC with particular focus on mobilization , or OC .  A total of 397 hip fracture patients , age 70 years or older , home dwelling , and able to walk 10 m before the fracture , were included . Primary outcome was measurement of upright time ( st and ing and walking ) recorded for 24 hours the fourth day postsurgery by a body-worn accelerometer-based activity monitor . Secondary outcomes were number of upright events on Day 4 , need for assistance in ambulation measured by the Cumulated Ambulation score on Days 1 - 3 , and lower limb function measured by the Short Physical Performance Battery on Day 5 postsurgery . RESULTS A total of 317 ( CGC n = 175 , OC n = 142 ) participants wore the activity monitor for a 24-hour period . CGC participants had significantly more upright time ( mean 57.6 vs 45.1 min , p = .016 ) , higher number of upright events ( p = .005 ) and better Short Physical Performance Battery scores ( p = .002 ) , than the OC participants . Cumulated Ambulation score did not differ between groups ( p = .234 ) . CONCLUSIONS When treated with CGC , compared with OC , older persons suffering a hip fracture spent more time in upright , had more upright events , and had better lower limb function early after surgery despite no difference in their need for assistance during ambulation A series of 80 patients with cervical , trochanteric or subtrochanteric hip fractures were r and omized to either treatment without traction , skin traction , or skeletal traction during the 1883 h between admission and operation . The institution of skin or skeletal traction was not particularly painful for the patient , but we found no indication that either was of discernible benefit . The number of analgesic medications needed was no higher in patients without traction . We conclude that traction should not be administered routinely to patients awaiting operation for hip fracture Objective : To test the effect of a follow-up clinic on urinary incontinence ( UI ) and nocturia  among older adults with hip fracture . Method : Fifty-three older adults ( ≥65 years ) 3 to 12 months following hip fracture were enrolled and r and omized to receive usual care plus the intervention ( B4 ) , or usual care ( UC ) only . The B4 group received management by health professionals , with need-based referrals . UI , nocturia , and quality of life were measured with question naires at baseline , 6 months , and 12 months . Results : There were 48 participants included in this analysis , and at baseline , 44 % of study participants self-reported UI . At final assessment , six out of 24 B4 participants and 12 out of 24 UC participants reported UI . Four out of five study participants reported nocturia at baseline ; this did not decrease during the study . Discussion : Following hip fracture , many older adults report UI and most report nocturia . Health professionals should be aware of the high occurrence of urinary symptoms among older adults post hip fracture One hundred twenty patients with cervical or trochanteric hip fractures were allocated r and omly to groups receiving either skin traction or no special treatment while awaiting surgery .  No differences were found between the groups in terms of pain experienced , the need for supplementary analgesics , or complications during the hospital stay . In addition , the repositioning and percentage of united fractures after 4 months did not differ significantly between the groups . The application of skin traction offered no benefits , and thus routine use of preoperative skin traction in patients with hip fractures is not recommended BACKGROUND Delirium and pain are common following hip fracture . Untreated pain has been shown to increase the risk of delirium in older adults undergoing elective surgery . This study was performed to examine the relationship among pain , analgesics , and other factors on delirium in hip fracture patients . METHODS We conducted a prospect i ve cohort study at four New York hospitals that enrolled 541 patients with hip fracture and without delirium . Delirium was identified prospect ively by patient interview supplemented by medical record review . Multiple logistic regression was used to identify risk factors . RESULTS Eighty-seven of 541 patients ( 16 % ) became delirious . Among all subjects , risk factors for delirium were cognitive impairment ( relative risk , or RR , 3.6 ; 95 % confidence interval , or CI , 1.8 - 7.2 ) , abnormal blood pressure ( RR 2.3 , 95 % CI 1.2 - 4.7 ) , and heart failure ( RR 2.9 , 95 % CI 1.6 - 5.3 ) . Patients who received less than 10 mg of parenteral morphine sulfate equivalents per day were more likely to develop delirium than patients who received more analgesia ( RR 5.4 , 95 % CI 2.4 - 12.3 ) . Patients who received meperidine were at increased risk of developing delirium as compared with patients who received other opioid analgesics ( RR 2.4 , 95 % CI 1.3 - 4.5 ) . In cognitively intact patients , severe pain significantly increased the risk of delirium ( RR 9.0 , 95 % CI 1.8 - 45.2 ) . CONCLUSIONS Using admission data , clinicians can identify patients at high risk for delirium following hip fracture . Avoiding opioids or using very low doses of opioids increased the risk of delirium . Cognitively intact patients with undertreated pain were nine times more likely to develop delirium than patients whose pain was adequately treated . Undertreated pain and inadequate analgesia appear to be risk factors for delirium in frail older adults Background There is a large quality of care gap for patients with osteoporosis . As a fragility fracture is a strong indicator of underlying osteoporosis , it offers an ideal opportunity to initiate investigation and treatment . However , studies of post-fracture population s document screening and treatment rates below 20 % in most setting s. This is despite the fact that bone mineral density ( BMD ) scans are effective at identifying patients at high risk of fracture , and effective drug treatments are widely available . Effective interventions are required to remedy this incongruity in current practice . Methods This study review ed r and omised controlled trials ( RCT ) involving fully qualified healthcare professionals caring for patients with a fragility fracture in all healthcare setting s. Any intervention design ed to modify the behaviour of healthcare professionals or implement a service delivery change was considered . The main outcomes were  BMD scanning and osteoporosis treatment with anti-resorptive therapy .  The electronic data bases Medline and Embase were search ed from 1994 to June 2010 to identify relevant articles in English .  Post-intervention risk differences ( RDs ) were calculated for the main outcomes and any additional study primary outcomes ; the trials were meta-analysed . Results A total of 2814 potentially relevant articles were sifted ; 18 were assessed in full text . Nine RCTs evaluating ten interventions met the inclusion criteria for the review . All were from North America . Four studies focused on patients with a hip fracture , three on fractures of the wrist/distal forearm , and two included several fracture sites consistent with a fragility fracture . All studies reported positive effects of the intervention for the main study outcomes of BMD scanning and osteoporosis treatment . For BMD scanning the overall risk ratio ( 95 % CI ) was 2.8 ( 2.16 to 3.64 ) ; the RD was 36 % ( 21 % to 50 % ) . For treatment with anti-resorptive therapy the overall risk ratio ( 95 % CI ) was 2.48 ( 1.92 to 3.2 ) ; the RD was 20 % ( 10 % to 30 % ) . Conclusions All interventions produced positive effects on BMD scanning and osteoporosis treatment rates post-fracture . Despite sizeable increases , investigation and treatment rates remain sub-optimal . Long-term compliance with osteoporosis medications needs to be addressed , as the majority of studies reported treatment rates at six-month follow up only . Studies would be more informative if treatment criteria were defined a priori to facilitate underst and ing of whether patients were being treated appropriately and integrated economic analyses would be helpful for informing policy implementation decisions PURPOSE Best rehabilitation practice s after hip fracture for people with dementia have not been established . A systematic review was conducted to determine current evidence for rehabilitation in this population , including residents in continuing care . METHODS St and ardized review methodology was used to search eight data bases for literature on  hip-fracture rehabilitation for people with dementia . Eligible studies included participants with dementia who had a hip fracture ; performed a rehabilitation intervention ; and evaluated one or more of function , ambulation , discharge location , or falls . The Newcastle-Ottawa Scale was used to assess validity . RESULTS A total of 13 studies were included : five r and omized controlled trials ( RCTs ) , seven prospect i ve cohort series , and one retrospective cohort study . Average quality ratings for RCTs and cohort studies were good and fair respectively . Participants with mild to moderate dementia receiving rehabilitation showed similar relative gains in function to those without dementia . Only one study examined the effect of rehabilitation among residents in continuing care . CONCLUSIONS People with mild or moderate dementia may show improved function and ambulation and decreased fall risk after rehabilitation post hip fracture , similar to gains achieved by those without dementia . More research is required to ascertain the effect of rehabilitation in people with moderate to severe dementia , including those residing in continuing-care setting s. Purpose : Best rehabilitation practice s after hip fracture for people with dementia have not been established . A systematic review was conducted to determine current evidence for rehabilitation in this population , including residents in continuing care . Methods : St and ardized review methodology was used to search eight data bases for literature on hip-fracture rehabilitation for people with dementia . Eligible studies included participants with dementia who had a hip fracture ; performed a rehabilitation intervention ; and evaluated one or more of  function , ambulation , discharge location , or falls . The Newcastle – Ottawa Scale was used to assess validity . Results : A total of 13 studies were included : five r and omized controlled trials ( RCTs ) , seven prospect i ve cohort series , and one retrospective cohort study . Average quality ratings for RCTs and cohort studies were good and fair respectively . Participants with mild to moderate dementia receiving rehabilitation showed similar relative gains in function to those without dementia . Only one study examined the effect of rehabilitation among residents in continuing care . Conclusions : People with mild or moderate dementia may show improved function and ambulation and decreased fall risk after rehabilitation post hip fracture , similar to gains achieved by those without dementia . More research is required to ascertain the effect of rehabilitation in people with moderate to severe dementia , including those residing in continuing-care setting There has been recent media attention to the possibility that long-term proton pump inhibitor ( PPI ) prescribing may be linked to an increased risk of hip fracture  according to data from the United Kingdom ( UK ) ( 1 ) and Canada ( 2 ) . The Canadian Association of Gastroenterology has prepared the following position statement on the association between PPI therapy and hip fracture in light of this evidence . The present position statement is outlined in greater detail elsewhere ( 3 ) . Yang et al ( 1 ) reported a nested case-control study using the UK General Practice Research Data base that selected patients older than 50 years of age with an incident hip fracture , and age and sex-matched controls . There were 13,556 hip fracture cases and 135,386 controls ;  PPI therapy for more than one year was associated with an increased risk of hip fracture ( adjusted OR 1.44 ; 95 % CI 1.30 to 1.59 ) . Targownik et al ( 2 ) reported a further nested case-control study using the Manitoba Population Health Research Data Repository , in which 15,792 patients with osteoporosis-related fractures were compared with 47,289 controls . There was no overall association between  PPI use and fracture until after five or more years of exposure , when the risk of osteoporotic fracture became significant ( adjusted OR 1.62 ; 95 % CI 1.02 to 2.58 ) . Similarly , the risk of hip fracture became significant after seven years of PPI exposure ( adjusted OR 4.55 ; 95 % CI 1.68 to 12.29 ) . The clinical significance of this is uncertain because extrapolation of these figures ( assuming 1.8 per 1000 patients develop a hip fracture [ 1 ] ) suggests that 1263 patients need to be treated with a PPI for more than one year to develop one excess hip fracture , although the number needed to harm may be much lower after seven years according to the Canadian study . These studies use reputable data bases and are rigorously conducted and analyzed appropriately . The discussion s in both of these articles suggest quite strongly that the association they have found is likely to be causal . Large data bases provide a wonderful opportunity to evaluate benefits and harms of medical interventions , but caution must be exercised before assuming the latest finding represents a risk to patients . The ready availability of data bases means that literally millions of associations can be tested ; even within a particular hypothesis there are a variety of approaches to splitting the data ( eg , duration of therapy , therapy dose , length of follow-up , patient age , male versus female ) . Research ers and journals are prone to emphasize positive findings and tend to underplay the role of chance or confounding factors . These issues are less likely to be important if a consistent association is found . An accompanying editorial ( 4 ) to the Canadian study also cites a third Danish data base study ( 5 ) that supports an association between PPI therapy and fracture . It is interesting to note that the Danish study had a much greater number of cases ( 124,655 ) than the other two studies , and yet had much more muted conclusions and was published in a lower impact factor journal . The Danish study was circumspect in their conclusions because there were inconsistencies in the data and there was no dose response information . For example , there seemed to be an increased risk with taking less than 25 doses of a PPI in one year with a lower ( but still statistically significant ) risk in those taking one dose per day for a year . There seemed to be no biologically plausible hypothesis why such infrequent use of PPI therapy would be associated with an increased risk of fracture . There were also inconsistencies with the UK and Canadian studies . The UK study reported an increased risk of hip fracture after one year of PPI therapy ; there seemed to be little increase in risk over the next four years , whereas the Canadian study only found a significant association after seven years . Targownik et al ( 2 ) suggest that perhaps the UK data base included patients that had in fact been taking PPIs for much longer ; however , this is speculation . Furthermore , a Canadian cohort study ( 6 ) followed-up on elderly patients in Ontario on  warfarin ( n=52,701 ) , thyroid replacement  ( n=40,555 ) , oral corticosteroid ( n=43,915 ) and PPI therapy  ( n=60,383 ) for five years . There was no increased risk of hip fracture in those taking warfarin compared with those on PPI therapy ( adjusted OR 0.94 ; 95 % CI 0.81 to 1.09 ) , but there was an increased risk with  corticosteroid therapy compared with PPI therapy ( adjusted OR 1.44 ; 95 % CI 1.21 to 1.70 ) . It could be that warfarin is also associated with an increased risk of hip fracture ; however , it is interesting that Targownik et al ( 2 ) found little increase in fracture risk in those taking anticoagulants ( 14.5 % of fracture cases taking anticoagulants compared with 13.4 % of controls ) . The CAG is proud to acknowledge its Benefactor Corporate Sponsors : Abbott Canada AstraZeneca Canada Inc Axcan Pharma Inc Olympus Canada Inc Pentax Canada Inc. Procter & Gamble Pharmaceuticals Schering-Plough Canada Inc. UCB Pharma Inc. Finally , there is the issue of biological plausibility . It has been proposed that acid suppression may reduce calcium absorption and increase the risk of fracture ( 1 ) . The role of pH in calcium absorption is , however , controversial . The dissolution of calcium carbonate is pH-dependent in vitro , although the clinical significance of this is uncertain given that calcium is absorbed in the small intestine where the pH is nonacidic regardless of stomach pH. A review of the literature ( 7 ) identified seven r and omized trials that evaluated calcium absorption with acid suppression in healthy subjects or those with ulcer disease . There were major method ological issues with many of the studies and they were all small . Four studies found no impact on calcium absorption while three reported decreased absorption . Further work is needed in this area , but there are no conclusive data that would make the association between fracture and PPI biologically plausible . Furthermore , some research suggests that PPI therapy may inhibit bone resorption ( 8) , which may protect against fracture risk . PPIs are one of the most well-tolerated classes of drugs on the market . They have also improved the quality of life of countless patients with acid-related disease . There are risks in prescribing any drug and this should be borne in mind by all prescribing clinicians . PPI therapy should only be prescribed for indications where there is a proven or likely benefit and the need for these drugs should be review ed on a regular basis . This applies particularly to frail and elderly patients with multiple comorbidities and those taking a number of different medications where the possibility for drug interactions increases . This message applies to all the drugs clinicians prescribe including PPI therapy . Current data would not support particular care in prescribing PPI therapy due to concerns about the risk of hip fracture . There is no persuasive evidence that the association is causal , although this can never be excluded as a possibility . The Canadian Association of Gastroenterology encourages health professionals to keep continually up date d on the medical literature and will endeavour to disseminate further guidance if more information on the possible harms of PPI therapy becomes available Background and Purpose Aquatic physical therapy is frequently used in the management of patients with hip and knee osteoarthritis ( OA ) , yet there is little research establishing its efficacy for this population . The purpose of this study was to evaluate the effects of aquatic physical therapy on hip or knee OA . Subjects A total of 71 volunteers with symptomatic hip OA or knee OA participated in this study . Methods The study was design ed as a r and omized controlled trial in which participants r and omly received 6 weeks of aquatic physical therapy or no aquatic physical therapy . Outcome measures included pain , physical function , physical activity levels , quality of life , and muscle strength . Results The intervention result ed in less pain and joint stiffness and greater physical function , quality of life , and hip muscle strength . Totals of 72 % and 75 % of participants reported improvements in pain and function , respectively , compared with only 17 % ( each ) of control participants . Benefits were maintained 6 weeks after the completion of physical therapy , with 84 % of participants continuing independently . Discussion and Conclusion Compared with no intervention , a 6-week program of aquatic physical therapy result ed in significantly less pain and improved physical function , strength , and quality of life . It is unclear whether the benefits were attributable to intervention effects or a placebo response
Overall , moderate evidence suggests that nerve blockades are effective for relieving acute pain and reducing delirium .
Low-level evidence suggests that preoperative traction does not reduce acute pain .
Nerve blockade seems to be effective in reducing acute pain after hip fracture .
Sparse data preclude firm conclusions about the relative benefits or harms of many other pain management interventions for patients with hip fracture .
BACKGROUND  Pain management  is integral to the management of hip fracture .
PURPOSE To review the benefits and harms of pharmacologic and nonpharmacologic interventions for managing pain  after hip fracture .