Conference Abstracts

Low operative rates associated with higher 30-day mortality following hip fracture; findings from the Fractures-E3 longitudinal study in Zimbabwe 

Burton A, Wilson H, Manyanga T, Mushayavanhu P, Masters J, Graham JM, Ndekwere M, Costa M, Ferrand RA, Gregson CL

Objective 

To characterise the population experiencing hip fractures in Harare, Zimbabwe and assess 30-day outcomes. 

Methods 

All hip fractures in adults aged ≥40 presenting to 1 of 7 hospitals in Harare were identified over 1 year (2021-22). Data were collected for all cases (age, sex, region of residence, presentation date, delayed presentation [i.e. >2weeks from injury], injury mechanism, fracture type). After consent patients were followed-up to 30-days with data collected on anthropometry, surgical management and mortality. Associations were tested using T-tests and chi-squared tests. 

Results 

Overall, 237 hip fracture cases were identified (123[51.9%] female; mean age 72.4[SD14.2] years), 87.3% followed low impact trauma, e.g. falls, and 81[34.2%] presented >2 weeks after injury. Household income was ≤$100USD/month in 60.6%. By 30-days 24[10.1%] had died. High impact trauma, e.g. traffic accidents, were more common in men than women (26[22.8%] vs. 4[3.3%], p<0.001), whilst presentation delays were similar by sex (45[36.6%] vs. 36[31.6%], respectively, p=0.42). 

In the 193 [82.8%] participants consenting to follow-up, 71[43.3%] had a mid-upper arm circumference <25cm (indicating malnutrition), 26[13.5%] reported living with HIV (96% on treatment), 5.3% had known diabetes and 27.8% hypertension. Overall, 113[61.1%] had an operation, with age similar between those operated and non-operated (mean[SD] 70.7[14.6] vs. 73.2[13.4] years, p=0.23). Higher household income was associated with operative management (74.6% operated if income >$100/month, 53.5% if <$100/month, p=0.005). Those attending private vs. public hospitals were more likely to have an operation (17[85.0%] vs. 96[55.5%], p=0.01). Non-operative management was associated with higher 30-day mortality (16[20.0%] vs. 2[1.8%], p<0.001). 

Conclusion 

In Zimbabwe, where malnutrition and HIV infection are common, most adult hip fractures are fragility fractures (national adult HIV prevalence is 12.9%). Non-operative management was common and associated with higher mortality. Reasons for not operating may include lack of surgical capacity, perceived surgical risk and/or patient inability to pay. Understanding barriers to operative management is important to inform future healthcare delivery. 

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Allopathic medical and traditional bone setter  fractures service availability and readiness in the Gambia

Burton A/Jarjou L, Marenah K, Wedner S, Graham S, Masters J, Jallow A, Wilson H, Costa M, Ward K, Gregson CL

Abstract

Objective 

To identify and quantify hip fracture service availability and readiness in The Gambia (adult population: 1.2million) 

Methods 

All health care facilities to which a person with a hip fracture could present were identified through Gambian Government Ministry of Health, regional directorates and health service-related networks; traditional bonesetters (TBS) were included as medical pluralism is common in The Gambia. From Oct2021-Dec2022 all facilities completed a modified WHO Service Availability & Readiness Assessment, in person with a trained fieldworker (5% completed by phone), with data captured in REDCap. Capacity per 100,000 adults ≥18 years in the population was quantified using global burden of disease population estimates 2010-2019 extrapolated to 2022 assuming linear growth.   

Results 

Nationally, 152 medical facilities were identified, 3 declined to participate. Of 149 participating facilities, 99 were public (41 community health centres, 19 rural or district hospitals, 6 regional or provincial hospitals, 3 central hospitals), 14 private and 36 either non-governmental organisations, religious, service, or research facilities. These 149 facilities provided a total of 2470 inpatient beds, 198.2 per 100,000 adults, of which 195 beds were trauma & orthopaedic (15.6/100,000). There were 426 doctors (34.2/100,000) of which just 9 were orthopaedic and trauma surgeons (0.8/100,000).  

Seven (4.7%) facilities had available and functional radiography facilities, with 28 radiographers reported across all facilities (2.2/100,000). Five (3.4%) facilities could provide diagnostic investigation and surgery for hip fractures (0.4/100,000), only one was a public facility. These 5 facilities reported 155 hip fractures in 2020.  

Of the 42 TBS identified, 35 (83.3%) chose to participate. Most (91.4%) had been trained by another TBS family member. The median period worked as a TBS was 20 years (range 2-72). 71.4% reported being able to set a hip fracture, and 25.7% had treated a hip fracture in the previous year. 

Conclusion 

Health services provision for diagnosis and treatment of hip fractures in The Gambia is low, and likely similar in the wider West Africa region. As lifespans increase so will the number of fragility fractures; fracture services, potentially including TBS, will need to expand to meet demand.  

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Incidence and number of hip fractures in South Africa: estimated projections from 2020 to 2050,  August 2021

Hawley S, Dela S, Burton A, Paruk F, Cassim B, Gregson CL

Conference presentation, Bone Research Society annual Meeting 2021 and NOFSA

Abstract

Background

Hip fracture is an established major public health problem among older adults in high-income settings; however, data from the sub-Saharan African region are scarce. Yet, this century, the number of older adults in sub-Saharan Africa is expected to grow faster than any other region globally. We aimed to use emerging data on hip fracture incidence in South Africa to estimate future burden of hip fracture for the country over the next three decades.

Methods

Previously collected data on hip fracture patients from eight districts within the Gauteng, KwaZulu-Natal and Western Cape regions of South Africa were re-analysed. All patients aged ≥40 years with a radiograph-confirmed hip fracture over a 12-month period in one of 94 included hospitals were enrolled. High-velocity trauma, pathological and peri-prosthetic fractures were excluded. Age-, sex- and ethnicity-specific incidence rates were generated and standardised to the 2011 South African census population and to future South African population projections estimated by the United Nations (UN). A correction factor was applied to UN projections for the population size aged ≥80 years, derived from the under-estimated 2011 UN population size compared to the South African 2011 census.

Results

The 2767 included hip fracture patients had mean (SD) age 73.7 (12.7) years; 69% were female. Incidence rates (per 100,000 people), standardised to the estimated South African population in 2020, were 104 for females and 47 for males. Rates for Black Africans (the largest ethnic group in South Africa; 79.2% of total population) were lower at 63 for females and 40 for males. Overall projected incidence rates were discernibly higher by the year 2040 (122 and 53 for females and males, respectively) and increased further by the year 2050 (141 and 60 for females and males, respectively). In terms of the overall annual number of hip fractures for the country, estimates increased from approximately 10,000 in 2020 to approximately 23,000 by 2050 (approximately 16,500 in Black Africans and approximately 6500 in other ethnic groups). The overall and age-stratified number of hip fractures are shown in the figure.

Conclusion

The hip fracture burden for South Africa, whose last census population was 52 million, is estimated to more than double over the next 30 years, to approximately one-third of those currently seen in the UK. Significant investment in fracture prevention services and inpatient fracture care is likely to be needed to meet this demand.

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Healthcare costs of acute hip fractures in South Africa, August 2021

Conference presentation at NOFSA

Abstract