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Commentary & Perspective | ||||||||
The following letters are published as a response to the article “Prevention of Hip Fracture in Elderly People with Use of a Hip Protector,” by Kannus et al., which appeared in The New England Journal of Medicine, 2000 Nov 23: 343:1506. To The Editor: The article in The New England Journal of Medicine, “Prevention of Hip Fracture in Elderly People with Use of a Hip Protector,” by Kannus et al., has important implications for orthopaedic surgeons. The occurrence of a hip fracture requires two conditions, one being an inherent weakness in the bone, such as osteoporosis, and the other, trauma to the bone, such as a fall. Elderly patients frequently fall to the side and are unable in many cases to protect themselves with their upper extremities, so they frequently impact the lateral side of the hip with the full force of the fall. There are many ways to try to prevent hip fractures and, in the last few years, we have seen the advent of pharmacologic treatment of osteoporosis which can be very effective in reversing bone loss and reducing the incidence of fractures. Most medications used to treat osteoporosis, however, work slowly and do not produce a significant decrease in the incidence of hip fractures until about 18 months after the onset of treatment. There is, therefore, a substantial period of time when, even though these patients are under treatment, they are still seriously at risk for hip fracture. Attenuating
the force applied to the greater trochanter at the time of impact is not a new
idea. In 1997, at the World Congress on Osteoporosis in Washington D.C., I heard
a paper presented on the benefits of hip-fracture padding. At that time, however,
there were no commercially available hip pads and it was impossible to obtain
anything for use in practice. At the most recent World Congress in Chicago (June,
2000), a paper presented by K. Hindso and co-workers from the Department of Orthopedics
at the University of Copenhagen, Denmark, reviewed the cases of 303 elderly orthopedic
patients admitted with primary hip fractures who were later given hip protectors
to wear. Sixty-five percent of the patients who were offered hip protectors accepted
them, and there were 244 patients who were controls. After a follow-up of one
to one and a half years, those patients who used the hip protectors every day
on a regular basis had no new hip fractures. The annual rate of second hip fractures
in the control group was 4.6% (p=0.03). The authors concluded that regular use
of hip protectors produced a significant protective effect among hip fracture
patients against second hip fractures. Hip pads are now commercially available and I have several patients in my practice wearing them daily. One is an elderly lady with osteoporosis who has fallen several times and sustained several fractures. Although currently on pharmacologic treatment, she is still at significant risk. She was somewhat reluctant at first to use the hip pads but now uses them every day. In most of the studies on hip protectors, compliance has been the biggest problem. I believe, however, that if we properly explain to our patients the devastating consequences of a hip fracture and the fact that these pads can be extremely effective in reducing their occurrence, most patients will readily accept them. In summary, I believe that the article by Kannus et al. is extremely relevant to orthopaedic surgeons. I believe that we orthopaedic surgeons have the responsibility of not only treating fractures in our patients, but also of preventing them. This is certainly an easy, safe and efficacious tool that we all have now at our disposal. John D. Kaufman, MD
To The Editor: We read with great interest the article "Prevention of Hip Fracture in Elderly People with Use of a Hip Protector", by Kannus et al., that appeared recently in The New England Journal of Medicine. This article contains important information for orthopaedic surgeons. Kannus and his colleagues in Finland reported the results of the use of an external hip protector in elderly people who were identified at significant risk for hip fracture. This large, prospective, randomized, controlled study demonstrated clear and definitive results. The use of an external hip protector dramatically decreased the incidence of hip fractures compared with that in the control group; specifically, the rate of hip fracture was more than doubled in the control group. Why is this study important? As orthopaedic surgeons, we have been responsible for the development of a wide variety of techniques to treat hip fractures successfully. We have also recognized the absolute necessity of treating the entire patient in order to maximize functional recovery. However, we have been less focused on the prevention of hip fractures. Each year, over 300,000 hip fractures occur in this country-all of which will be treated by orthopaedic surgeons. However, how many of us take steps to initiate treatment of the underlying factors that predispose a patient to fracture-specifically, a history of falling or osteoporosis? In addition, many of us provide orthopaedic consultation to skilled nursing facilities or senior living centers and treat the hip fractures that occur. However, how many of us have initiated a prevention program for this high-risk population? Although we are expert in treating these fractures, we need to expand our role in the overall management of these elderly patients. This expansion should occur in two specific areas. First, since studies have shown that management of elderly hip-fracture patients can be improved when a multidisciplinary approach is used, we should work collaboratively with our internal medicine/geriatrician colleagues to develop interdisciplinary care models. We can provide important leadership in this effort and not just be responsible for "fixing the fracture". Second, we should emphasize prevention of hip fractures in the care of our patients who sustain fractures as well as those who are at high risk. The data provided by Kannus and colleagues provide us with another effective method of prevention in addition to the pharmacologic approach and those falls-prevention measures currently being utilized. The care and treatment of hip fractures in elderly people is a very important responsibility of orthopaedic surgeons. As health care has increasingly focused on these patients, it has become increasingly important for orthopaedic surgeons to expand their role as leaders in the management of this important and expanding patient population. Joseph D. Zuckerman, MD | ||||||||
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