Osteoporotic hip fracture, already a dangerous and debilitating problem for older men and women worldwide, is poised to become a far more severe global public-health issue as the population grows older and frailer, according to a new study led by researchers at the University of Hong Kong. The findings hold importance for India whose elderly population (aged 60 and above) is projected to touch 194 million in 2031 from 138 million in 2021, a 41 per cent increase over a decade, according to the National Statistical Office (NSO)’s Elderly in India 2021 report. Hence, requiring immediate attention by the medical and public health community. The HEALTH PIONEER talks to a battery of doctors on various aspects of the osteoporotic hip fracture and remedies therefore.
The Hong Kong study findings were presented recently at the annual meeting of the American Society of Bone and Mineral Research in Austin, Texas. It analyzed data in 19 countries for patients 50 and older who had fractured their hips between 2005 and 2018. It found that total hip fracture counts were expected to increase over time in 18 of the 19 countries. Hip fracture counts were projected by 2030 and 2050 using predicted population size provided by the World Bank. By 2050, the worldwide hip fracture counts will have likely doubled compared with 2018, with a larger proportional increase in men than women.
The study noted some possible reasons for the sex discrepancy. Although the incidence of hip fractures declined in most countries during the study period, the magnitude of decline was smaller for men. Men's life expectancy, meanwhile, has been increasing, a result of better medical care, hygiene, diet, and other factors. The United Nations projects that the life expectancy of men globally will likely reach over 75 years by 2050, the age after which this study showed a high risk of hip fracture. Thus, researchers expect that the proportion of men with a high risk of hip fracture will grow.
Ching-lung Cheung, Associate Professor, in the University of Hong Kong’s Department of Pharmacology and Pharmacy, presented the findings recently at the annual meeting of the American Society of Bone and Mineral Research in Austin, Texas.
At the same time, osteoporosis in men has been underdiagnosed and undertreated for years, Dr. Cheung reported. "Our study also showed that the use of anti-osteoporosis medications following a hip fracture is lower in men than in women by 30% to 67%," he said. "Thus, more attention should be paid to preventing and treating hip fractures in men."
Previous reports on hip fracture incidence are based on outdated data with heterogeneity in methods and study periods. This study examined the most currently available secular trends of hip fracture incidence, mortality, and use of post-fracture pharmacological treatment across 19 countries.
A common protocol and a common data model were applied across all sites to provide comparable data. Age- and sex-standardized annual incidence of hip fracture, mortality, and pharmacological treatment rates within 12 months were calculated.
Using descriptive analyses of patient-level healthcare data, the researchers found wide variability among the 19 countries studied. The overall age- and sex-standardized incidence of hip fracture was estimated to be 180 per 100,000 individuals (Women 236; Men 118). But the average change in hip fracture incidence varied from -2.8% to +2.1% per year. The most pronounced declines in fractures were seen in Denmark (-2.8%), Singapore (-2.8%), and Hong Kong (-2.4%). The biggest increases were in the Netherlands (+2.1%), and South Korea (+1.2%). One-year all-cause mortality ranged from 14.4% to 28.3%, while mortality trends varied from -5.3% to +18.4% per year, with the largest decreases in Australia (-5.3%), the Netherlands (-4.6%), and Singapore (- 4.3%). Use of anti-osteoporosis medications within 12 months of hip fracture ranged from 11.5% to 50.3%, with trends varying from -9.6% to +12.7% per year and declining in 6 out of 15 sites.
The reasons for the observed variability among countries would require further in-depth research, co-author Chor-Wing Sing, a research assistant professor said. "One potential reason that some countries have seen relatively large declines in hip fractures is better osteoporosis management and post-fracture care," she said. "Better fall-prevention programs and clearer guidelines for clinical care have likely made a difference." Dr. Sing also noted people's greater awareness of bone health, resulting in an increase in bone mineral density, or BMD, may also have helped. She cited a study in Hong Kong, which had one of the largest declines in hip fractures, which showed that women 50 and older had become more physically active and started doing more weight-bearing exercise, resulting in a significant long-term increase of BMD.
The new study's key message, the authors said, is that the decline in hip fractures in many countries in recent years is not enough to offset the effect of the growing aging population. The burden of hip fracture is going to grow. But post-fracture treatment remains inadequate in many countries. Meanwhile, the incidence of hip fracture in people over 85 (the “oldest old”) remains more than double that of other age groups, while post-fracture treatment in this population is generally conservative. A larger and more collaborative effort among healthcare providers, patients, and caregivers will be needed to prevent hip fractures and improve the treatment gap and post-fracture care, especially in men and the oldest old. This need is urgent, and growing, worldwide.
According to doctors, the worldwide annual incidence of hip fractures is estimated to be about 1.6 million and is expected to increase to 2.6 million by the year 2025 and 4.5 million by 2050 due to the aging population. Despite the morbidity associated with elderly hip fractures, few studies have evaluated the incidence and epidemiology of hip fractures in India.
They aver, as a result, the true figures on the incidence of hip fractures in India is lacking, though the annual incidence is estimated to be over 120 fractures per 100,000 persons over the age of 50, with higher rates in women. Considering that the population of India over 50 is close to 170 million according to the 2011 census, this translates to about 0.2 million hip fractures a year.
According to a study ‘Injury Mechanisms of Hip Fractures in India’, conducted by a team of orthopeadics led by Dr Vijay Sharma, a fall from a standing height is the predominant mode of injury among hip fractures in India.
Women and increasing age were associated with fall as the mechanism of injury of hip fracture. The majority of falls resulted from a wet floor or postural changes suggesting that education on environmental safety measures and on postural changes should be included in fall counseling.
“Public behaviour changes and elderly pedestrian safety measures should also be a part of hip fracture prevention programmes. Using the information presented in this study, further research to plan and assess fall prevention initiatives is recommended,” said the study published in journal Hip and Pelvis in 2021. The team members included Dr Jaiben George, Dr Kamran Farooque, Dr Samarth Mittal, Dr Vivek Trikha and Dr Rajesh Malhotra, all from Department of Orthopedic Surgery, All India Institute of Medical Sciences (AIIMS), New Delhi.
What is an osteoporotic hip fracture?
A femoral neck fracture happens 1 to 2 inches from your hip joint. This type of fracture is common among older adults and can be related to osteoporosis. This type of fracture may cause a complication because the break usually cuts off the blood supply to the head of the thighbone, which forms the hip joint.
Symptoms
l Inability to get up from a fall or to walk.
l Severe pain in the hip or groin.
l Inability to put weight on the leg on the side of the injured hip.
l Bruising and swelling in and around the hip area.
l Shorter leg on the side of the injured hip.
l Outward turning of the leg on the side of the injured hip.
They can damage surrounding muscles, ligaments, tendons, blood vessels, and nerves. If they're not treated right away, they could affect your ability to get around for long periods of time. When this happens, you run the risk of a number of complications, like: Blood clots in your legs or lungs
The risk of hip fracture can be increased if you have:
Osteoporosis: This condition weakens bones and makes them more likely to break.
Thyroid problems: An overactive thyroid can lead to fragile bones.
Intestinal disorders.: Conditions that reduce absorption of vitamin D and calcium also can cause weakened bones.
Problems with balance: Parkinson's disease, stroke and peripheral neuropathy can increase the risk of falling. Having low blood sugar or low blood pressure also can contribute to the risk of falls.
Certain medications: Cortisone medications, such as prednisone, can weaken bones if taken long-term. Certain drugs or certain combinations of medications can cause dizziness, which can increase the risk of falling. The most common drugs associated with falls include sleep medications, antipsychotics and sedatives.
Nutritional problems : Lack of calcium and vitamin D in the diet of young people lowers peak bone mass and increases risk of fracture later in life. It's also important to get enough calcium and vitamin D in older age to try to maintain bone density. Being underweight also increases the risk of bone loss.
Lifestyle choices : Lack of regular weight-bearing exercise, such as walking, can result in weakened bones and muscles, making falls and fractures more likely.
Tobacco and alcohol both can interfere with the normal processes of bone building and maintenance, resulting in bone loss.
Complications : A hip fracture can reduce independence and sometimes shorten life. About half the people who have a hip fracture aren't able to regain the ability to live independently.
When hip fractures prevent movement for a long time, complications can include:
l Blood clots in the legs or lungs
l Bedsores
l Pneumonia
l Further loss of muscle mass, increasing the risk of falls and injuries
l Death
Prevention: Healthy lifestyle choices in early adulthood build a higher peak bone mass and reduce the risk of osteoporosis in later years. The same measures adopted at any age might lower the risk of falls and improve overall health.
To avoid falls and to maintain healthy bone:
l Get enough calcium and vitamin D: In general, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
l Exercise to strengthen bones and improve balance: Weight-bearing exercises, such as walking, help maintain peak bone density. Exercise also increases overall strength, decreasing the risk of falling. Balance training also is important to reduce the risk of falls since balance tends to deteriorate with age.
l Avoid smoking or excessive drinking: Tobacco and alcohol use can reduce bone density. Drinking too much alcohol can also impair balance and increase the risk of falling.
l Assess the home for hazards: Remove throw rugs, keep electrical cords against the wall, and clear excess furniture and anything else that could trip people. Make sure all rooms and passageways are well lit.
l Check your eyes: Have an eye exam every other year, or more often if you have diabetes or an eye disease.
l Use a cane, walking stick or walker: If you don't feel steady when you walk, ask your doctor if these aids might help.
Could blood marker predict the risk of osteoporotic hip fracture in men?
Bone health requires a balanced activity of various bone cell types including bone-forming osteoblasts and bone-resorbing osteoclasts. Osteoporosis occurs when osteoclasts dominate without adequate bone formation to compensate. In new research published in the Journal of Bone and Mineral Research, elevated blood levels of a certain chemokine, or small signaling protein, that promotes osteoclast formation were linked with a higher risk of hip fracture in men.
The study included 55 men and 119 women who had experienced a hip fracture an average of 6.3 years after their blood was collected. The participants were matched individually to controls who did not develop hip fractures.
Investigators observed higher blood levels of the chemokine CXCL9 in the pre-fracture blood samples of men with subsequent hip fractures compared with their non-fracture controls. No such difference was seen women.
“The unexpected difference in the results between men and women in our study may be explained by how changes in sex hormone levels during aging could influence the level and effects of CXCL9 differently in older men and women,” explained corresponding author Woon-Puay Koh, from the National University of Singapore (NUS).
“Our findings open the exciting possibility that early interventions targeting CXCL9 or CXCL9-CXCR3 signalling could be beneficial in preventing hip fractures in older men,” added co-corresponding author Christoph Winkler, also from NUS.
Deborah Sellmeyer,, medical director of the Johns Hopkins Metabolic Bone Center warns that, “Older adults can have life-threatening complications during or after surgery to treat a hip fracture, such as blood clots, infections and heart arrhythmias.”
“That’s why it’s important to do all you can to prevent fractures—especially hip fractures.”
He give tips for hip fracture prevention
Take your risk seriously : One in three women and one in five men will have a fracture at some point after age 50.
Screen—and maintain—bone strength: Low bone density doubles or even triples hip fracture risk. That’s a major concern, because 56 percent of women and 18 percent of men age 50 and older have reduced bone mineral density, including the 16 percent of women and 2 percent of men with bone density low enough to be categorized as osteoporosis. Another 40 percent of women and 16 percent of men have osteopenia, a milder degree of low bone
density.
Bone density tests are recommended for all women age 65 and older, and for younger women at higher-than-normal risk for a fracture. Discuss your individual risk for fracture and need for bone density testing with your doctor. Screening for problems with bone density scans resulted in a 36 percent lower fracture risk in one Johns Hopkins study. Screening for osteoporosis lets you and your doctor make decisions about treatments that keep bones strong and fracture-free, Sellmeyer says.
Men may want to discuss osteoporosis screening with their doctor if they’re over age 70 or at risk for thinning bones due to factors such as long-term use of corticosteroid drugs, like prednisone.
Keep muscles strong: Nine out of 10 hip fractures are caused by falls. Exercises that maintain muscle strength, endurance and balance can lower your risk for the slips, trips and tumbles that break bones. In one study, women who had not exercised in a year were at higher risk for hip fracture, even if they did not have osteoporosis. A regular exercise routine can cut your risk of a fall by 20 percent to 30 percent, research has suggested.
Eat for a healthy frame : Aim for 1,000 mg of calcium daily for women before age 50 and men before age 70, then 1,200 mg for women over age 50 and men over age 70. “You also need vitamin D to help absorb calcium. The current recommendations are 600 IU per day up to age 70 and 800 IU after age 70,” Sellmeyer notes. “There’s no doubt that this combination reduces fracture risk.”
But don’t stop there. Get plenty of potassium-rich fruits and vegetables daily. And don’t skimp on protein, which seems to help by maintaining muscle mass (important for strength) and by helping build bones.
Check your eyes and your medicines : If you feel drowsy, dizzy, weak or off-balance when walking, ask your doctor for a medication check. Some prescription drugs can cause these fall-inducing side effects. “And stay up-to-date with vision checks and eyeglass prescriptions,” Sellmeyer says. “Sharp vision can also help you avoid a fall.”