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"documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Med Clin. 2015;145:465-70" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 3 "PDF" => 3 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Incidence of hip fracture in Spain (1997–2010)" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "465" "paginaFinal" => "470" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Incidencia de la fractura de fémur en España (1997–2010)" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1448 "Ancho" => 2186 "Tamanyo" => 192263 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Relationship between the year of birth (groups of 5 years), the time of peak bone mass and the years in which it is acquired (20–30 years) as possible “cohort effect”.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Rafael Azagra, Francisco López-Expósito, Juan Carlos Martin-Sánchez, Amada Aguyé-Batista, Paula Gabriel-Escoda, Marta Zwart, Miguel Angel Díaz-Herrera, Jesús Pujol-Salud, Milagros Iglesias Martínez, Núria Puchol-Ruiz" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Rafael" "apellidos" => "Azagra" ] 1 => array:2 [ "nombre" => "Francisco" "apellidos" => "López-Expósito" ] 2 => array:2 [ "nombre" => "Juan Carlos" "apellidos" => "Martin-Sánchez" ] 3 => array:2 [ "nombre" => "Amada" "apellidos" => "Aguyé-Batista" ] 4 => array:2 [ "nombre" => "Paula" "apellidos" => "Gabriel-Escoda" ] 5 => array:2 [ "nombre" => "Marta" "apellidos" => "Zwart" ] 6 => array:2 [ "nombre" => "Miguel Angel" "apellidos" => "Díaz-Herrera" ] 7 => array:2 [ "nombre" => "Jesús" "apellidos" => "Pujol-Salud" ] 8 => array:2 [ "nombre" => "Milagros" "apellidos" => "Iglesias Martínez" ] 9 => array:2 [ "nombre" => "Núria" "apellidos" => "Puchol-Ruiz" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775315001827" "doi" => "10.1016/j.medcli.2015.02.023" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775315001827?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020616300213?idApp=UINPBA00004N" "url" => "/23870206/0000014500000011/v1_201604300039/S2387020616300213/v1_201604300039/en/main.assets" ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial article</span>" "titulo" => "Hip fracture incidence in Spain" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "482" "paginaFinal" => "484" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Íñigo Etxebarria-Foronda" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Íñigo" "apellidos" => "Etxebarria-Foronda" "email" => array:1 [ 0 => "ietxe@yahoo.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Traumatología, Hospital Alto Deba, Mondragón, Guipúzcoa, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Incidencia de la fractura de cadera en España" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hip fracture is a serious clinical process and an important public health problem. First, due to its impact on the loss of hope and quality of life. It is associated with excess mortality and causes significant sequelae, causing varying degrees of dependency. Second, the cost incurred, both direct, in the hospital, with a significant use of resources and bed occupancy, as well as social, in connection with care dependency. Finally, due to the progressive aging of the population, demographic forecasts paint a “worrying horizon” as the authors emphasize in the current issue of the magazine. Their results show the progression of the incidence of proximal femur fractures in Spain in recent years and the variability between our different regions.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">This study finds that the incidence of these fractures is increasing in our country, consistent with all records worldwide. The benefit of lengthening the life expectancy is counterbalanced by the increase of certain conditions that have a direct relationship with longevity. Thus, risk factors for brittle fracture, like osteoporosis and loss of motor capacity, muscular strength and elasticity associated with aging, determine an absolute risk, which increases with the aging population. The older person is a patient especially susceptible to suffer from a number of osteoporotic profile fractures, among which are proximal femur fractures, commonly called “hip” fractures. In fact, 85% of these fractures in our country occur in patients over 75 years of age.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">One of the first considerations derived from these data is whether all the therapeutic arsenal we use for the treatment of osteoporosis actually makes sense, because the main and most serious fracture that supposedly we want to avoid, not only is not being reduced, but is on the increase. It is even more striking when we consider that we are one of the countries with the highest investment in connection with this purpose.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> In this sense, it seems clear that if a proper methodological analysis is performed, adjusting rates by age, there is a tendency to stabilize, and even decrease the incidence, at least in certain age groups.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> And precisely, this pharmacological treatment is one of the reasons that could justify this reverse trend.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">4</span></a> Consequently, we could think that this economic effort can have an impact on reducing a considerable number of fractures. An interesting aspect is the cohort effect cited in the paper,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> by which the most elderly patients, whose bone maturation time corresponds to the most difficult war and post-war years, could have had an inadequate peak bone mass. Its influence is very likely, since the reduction of fractures occurs especially in younger patients, whose bone development was out of this time period, as shown in the illustrative figure. But perhaps the most important reflection we can do in this area is to ensure that our young people have a healthy lifestyle, proper nutrition and adequate practice of sport during this critical period of intense bone metabolism, and that peak bone mass is the optimal, assuming that, from a certain age, we will only experience a negative physiological balance in the same. Other factors, such as genetic, environmental or sun exposure, are probably irrelevant, since there are no significant changes in these periods that may explain an influence on the incidence of such fractures.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Another important aspect is the variability between different regions, an issue which is consistent with other recently published works.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a> And we cannot clearly explain why. Traditionally, solar influence on bone health in the different Spanish regions has been a matter of controversy, but seeing the map appearing on the paper,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> except for the Canary Islands, the sunniest areas are, <span class="elsevierStyleItalic">in theory</span>, those with the highest rate of fractures. It seems that the way of life in rural communities, where there is increased physical activity in the last stages of life, could explain a lower incidence of fractures in these areas, although there is no clear comparative data in Spain. Physical exercise in old age is considered as one of the best strategies for preventing falls,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">6</span></a> and this may partly explain why certain aging communities have a lower adjusted rate of hip fracture. Another interesting question would be to analyze the various existing health policies in our country, especially what, perhaps, would be the most appraisable subject, the pharmacological treatment of osteoporosis. Has the therapeutic approach been the same in all of them? Is it now? It would be interesting to know the level of drug prescription in the different regions regarding the management of osteoporosis and the incidence of fractures. We can assume that many treatments may be wrongly indicated,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">7</span></a> that the secondary prevention of fractures is not enough<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8,9</span></a> and adherence to long-term treatment is worrying.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">10</span></a> Despite all this, it would be important to know if there were prescribing differences in the different regions, and by extension, if those in which there is more treatment coverage, there is also a lower incidence in the time of fractures. It is difficult to verify, but it is an interesting line of research, so as to help explain these differences between the different regions of Spain.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Regarding the “worrying horizon” that forecasts portend for the future, we must prepare to act on two scenarios: 1, coordinated approach of patients who have already suffered the fracture, in order to ensure a better progression of the same; and 2, establishing clear prevention strategies, especially in patients with a significant risk of suffering it.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Regarding the first scenario, a common trend seen in many hospitals is the orthogeriatric management of patients with hip fracture. The condition of the patient is severe and 3 clear lines of action are established: (1) surgical intervention as soon as possible; (2) intensive treatment and prevention of postoperative complications, and (3) support patient reintegration to normal daily activities as much as possible, considering that they are especially vulnerable people.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Most patients require surgical intervention to fix the fracture. Even in the worst damaged cases, surgery may relieve basic issues such as hygiene and mobilization at medium term. Currently, surgery performed in less than 48<span class="elsevierStyleHsp" style=""></span>h is considered a quality standard, target which is not always achieved in many of the Spanish centres.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">11</span></a> Early surgery reduces mortality, improves subsequent progression and considerably reduces the cost, something of paramount importance.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> The reasons for this excessive delay are partly due to clinical constraints, many of them in connection with the regular intake of antiplatelet and anticoagulant medication. Fortunately, the increasing involvement of anaesthesiologists in the optimal preoperative approach prevents unjustified delays in surgery that can and should be done in the established time. Perhaps most worrying is that in many circumstances, the delay is not due to medical causes, but rather administrative or organizational, an issue which indisputably must improve.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">13</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Proper postoperative management helps improve morbidity and mortality. Recent studies show that many of the errors committed in the treatment of patients with hip fracture were potentially preventable in almost 60% of cases.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">14</span></a> In that sense, it is considered that nearly half of deaths are “inevitable”, caused by previous serious diseases. The alarming thing is that the rest are due to “potentially preventable” postoperative complications.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> That's where coordinated multidisciplinary units are showing excellent results.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">16</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The last part of the process is helping the patient to return to daily activities, in the best way possible, considering that probably there will be a change in the degree of autonomy and motor skills, leading to, sometimes hard to accept, family and social burdens. The “circuit” for the social integration of the patient must be clearly established from the time of admission. Thus, appropriate medical and social coordination will avoid unnecessary stays in acute care hospitals and will contribute to a less traumatic adaptation to the new environment. In many centres, this is being achieved gradually, although there is still a long way to go.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The second scenario discussed above is prevention. We can establish two levels of prevention: primary, avoiding fracture and secondary, avoiding the appearance of new fractures once the first has occurred.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Primary prevention can be complex at the population level because osteoporosis has no symptoms unless there is a fracture. It requires the identification of patients at risk, based on their medical history and measuring their bone mineral density. FRAX<span class="elsevierStyleSup">®</span>, with its strengths and weaknesses, can be helpful, although sometimes it can be difficult to make a decision on a chronic treatment in an apparently healthy patient.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Secondary prevention is much simpler and should be a clear objective to achieve. The occurrence of a fragility fracture significantly increases the risk of new fractures as demonstrated with high levels of evidence.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">17</span></a> All clinical practice guidelines unanimously recognize the adequacy of this level of prevention after a hip or vertebral fracture, and more heterogeneous in males and the rest of fractures.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">18</span></a> Despite this, coverage rates are generally less than 20%.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8,9</span></a> It is perhaps one of the most important areas for improvement. Many hospitals have recently implemented what is called <span class="elsevierStyleItalic">Fracture Liaison Services</span>, a formula that ensures appropriate evaluation and treatment of all patients who have had an osteoporotic fracture, with proven results over time.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">19</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Finally, we must not forget fall prevention strategies.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> Measures can be implemented to reduce falls as much as possible in particularly susceptible populations, such as the elderly.</p><p id="par0070" class="elsevierStylePara elsevierViewall">In summary, we have a challenge ahead of us. The forecasts are not good, but we have effective measures to reduce its impact, both clinically and economically. Let's do it!</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Etxebarria-Foronda Í. Incidencia de la fractura de cadera en España. Med Clin (Barc). 2015;145:482–484.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0105" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidencia de la fractura de fémur en España (1997–2010)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Azagra" 1 => "F. López-Expósito" 2 => "J.C. Martin-Sánchez" 3 => "A. Aguyé-Batista" 4 => "P. Gabriel-Escoda" 5 => "M. 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Vol. 145. Issue 11.
Pages 482-484 (December 2015)
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Vol. 145. Issue 11.
Pages 482-484 (December 2015)
Editorial article
Hip fracture incidence in Spain
Incidencia de la fractura de cadera en España
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Íñigo Etxebarria-Foronda
Servicio de Traumatología, Hospital Alto Deba, Mondragón, Guipúzcoa, Spain
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