The epidemiological status of osteoporotic hip fractures: A bicentric comparative and retrospective study

Abstract

BACKGROUND:

Osteoporotic hip fractures have posed a significant burden to society, and more epidemiological data is required.

OBJECTIVE:

To compare the epidemiological differences of hip fracture patients in Spain and China.

METHOD:

This was a retrospective comparative study. Comparisons were made in terms of morbidity, demographic and anthropometric characteristics, length of stay, cost of hospitalization, and mortality by consulting the medical histories of osteoporotic hip fractures in two hospitals. The $t$ test was used for measurement data, and the $X^{2}$ test was used for count data. The difference is statistically significant when $p<$ 0.05.

RESULTS:

A total of 757 patients were enrolled in this study, with 426 from Virgen Macarena University Hospital (HUVM) and 331 from Xi’an Daxing Hospital (XDH). The average age was 81.4 $\pm$ 9.26 and 76.0 $\pm$ 8.08 years; the proportion of women was 74.9% and 68.0%, respectively. The incidence of osteoporotic hip fractures in Seville residents over 50 years old was approximately 239 per 100,000 residents, compared to 158 per 100,000 residents in Xi’an. The timing of surgery in Spanish patients was significantly longer than in Chinese patients, 78.7 $\pm$ 48.2 vs. 60.7 $\pm$ 43.1 hours, $p=$ 0.000. There were 81 deaths in Spain and 43 deaths in China during the one-year follow-up period ( $p=$ 0.026).

CONCLUSIONS:

In terms of incidence, demographics, surgical methods, and mortality, there are significant differences between hip fracture patients in Seville, Spain and Xi’an, China.

Keywords

Epidemiology hip fracture osteoporosis mortality

1. Introduction

Hip fracture, as a serious complication of osteoporosis, brings heavy nursing and economic burdens to patients, family members, and society. The number of hip fractures is increasing year after year as the world’s population ages [1]. According to reports, nearly 6.3 million hip fractures will occur each year in the world by 2050, with an estimated global total of 6.3 million hip fractures by 2050 [2]. Worldwide, there are significant differences in the epidemiology of hip fractures, such as age, sex ratio, incidence, and mortality, due to differences in culture, race, geography, economic level, and so on [3]. According to reports, Scandinavia has the highest incidence (439/10 ${}^{5}$ inhabitants/year in Denmark, 420/10 ${}^{5}$ inhabitants/year in Norway, 401/10 ${}^{5}$ inhabitants/year in Sweden), and the lowest incidence are in Tunisia (50/10 ${}^{5}$ inhabitants/year), Ecuador (55/10 ${}^{5}$ inhabitants/year) and Morocco (69/10 ${}^{5}$ inhabitants/year) [4].

Spain, as a developed country, has a large number of elderly people. According to data provided by Statistics National Institute, in 2020, the population over 65 years old was approximately 9.27 million, accounting for 19.58% (the total population was 47.35 million) [5]. This number will continue to increase in the next 30 years. A Spanish study showed that between 1999 and 2015, among people over 45 years of age with osteoporotic hip fractures, the average age was 83 years, of which 78% were women, and the overall incidence was 290/10 ${}^{5}$ people (428 for women; 134 for men), and it was found that during this period, the incidence of fractures decreased by 3.6% per year [6]. This is consistent with the findings of recent Spanish scholars Aguilar [7] and Rey [8]. In other words, the number of hip fractures appears to be decreasing in Spain. In the mortality report, the one-year mortality rate of hip fracture patients in Spain is more than 20% to 33% [6, 9]. As the world’s most populous developing country, China’s aging problem is becoming increasingly serious as life expectancy rises and health care improves. China has a vast territory and the epidemiology of hip fractures varies. A large study of approximately 460 million Chinese residents found that the absolute number of hip fractures increased by approximately four times between 2012 and 2016. The overall incidence rate, however, has remained relatively stable, with 149 cases per 100,000 inhabitants in 2012 and 137 cases per 100,000 inhabitants in 2016. The average age of hip fracture patients was 77.05 $\pm$ 8.94 years, of which 63.99% were female [10]. The total number of hip fractures in people over the age of 65 in China is expected to be 1.3 million by 2050 [11]. A recent meta-analysis showed that the one-year mortality rate for hip fracture patients in China was 13.96% [12].

Currently, the treatment methods for femoral neck fractures are essentially the same; that is, relatively young patients are treated with methods that retain the femoral head, such as hollow screws, and artificial joint replacements are used for the rest. For intertrochanteric fractures, especially the instability of the elderly, many Chinese scholars have reported the use of artificial joint replacement treatment, and good results have been achieved [13]. When compared to internal fixation, patients with artificial joint replacement can begin weight-bearing activities sooner and have fewer bed-ridden complications. In Spain, however, there has been no report of artificial joint replacement for the treatment of elderly people with unstable intertrochanteric fractures.

The cost of hip fracture varies with each country’s economic level and purchasing power. The average cost of hip fractures in the first year for women is 9,690 € and for men 9,019 €, according to a Spanish study. The main cost determinant is the first hospitalization (7,067 € and 7,196 € in women and men, respectively) [9]. According to a prospective study of the economic burden of hip fractures in western China, the total annual cost was $4,386 per person [14]. The cost is higher in China’s developed cities (such as Beijing or Shanghai), reaching $5,239 [15]. Most of the cost is associated with direct medical care. However, indirect costs cannot be ignored either. It can be seen that no matter in which country, the expensive cost of osteoporotic hip fractures has brought a huge economic burden to the family and the national health system.

Spain, as a typical representative of developed countries, and China is the largest developing country. There are differences in the epidemiology and mortality of hip fractures between these two countries. We selected two representative cities of these two countries to collect data on hip fracture patients in two large hospitals in order to gain insight into these differences and, to the greatest extent possible, reveal their causes, in order to provide reference and assistance for the epidemiology, prevention, and treatment of hip fractures.

2. Materials and methods

2.1 Patients

The study described in this article was a retrospective observational study. The patients came from two different hospitals: the Virgen Macarena University Hospital’s (HUVM) Department of Traumatology and Orthopedic Surgery in Seville, Spain, and the Xi’an Daxing Hospital’s (XDH) Department of Traumatology and Orthopedic Surgery in Shaanxi, China. The patients diagnosed with hip fracture had undergone surgical surgery during the period of time between January 1, 2017 and December 30, 2017. They were tracked for a year after the surgery. The ethics committees of HUVM in Spain and XDH in China approved this study (JA-HUVM-VR-201948101521).

2.2 Profiles of the two hospitals

The HUVM in Seville and the XDH in Shaanxi Province were chosen for the study because they are both in the upper-middle of their respective countries in terms of geographic location, population, or economic level, and have a good representation. Furthermore, these two hospitals are the largest tertiary general hospitals in the jurisdiction, and they treat nearly all hip fracture patients in the jurisdiction. According to data from Spain’s National Bureau of Statistics, the Hospital Macarena serves approximately 480,000 residents, with a 37% proportion of people over the age of 50 [5]. According to data from the Shaanxi Provincial Bureau of Statistics, the population of Daxing New District is about 800,000, of which 210,000 are over 50, accounting for 26% [16].

2.3 Inclusion and exclusion criteria

Inclusion criteria: (1) Age $\geqslant$ 50 years old; (2) Hip fracture diagnosed by radiology; (3) The type of hip fracture is femoral neck fracture or intertrochanteric fracture; (4) The fracture should be caused by osteoporosis, which is believed to be caused by spontaneous or minor trauma (usually an accidental fall); (5) Fresh fractures (within two weeks); (6) Patients with unilateral hip fractures; (7) Patients undergoing surgery; (8) Patients who have completed all follow-up data.

Exclusion criteria: (1) Under 50 years of age; (2) The type of fracture is femoral head fracture or subtrochanteric fracture; (3) Fractures are secondary to high-energy trauma (falls from heights or traffic accidents); (4) Old fractures; (5) Multiple fractures; (6) Pathological, fractures caused by other metabolic bone diseases, such as Paget’s disease, primary or metastatic bone tumors, or chronic osteomyelitis; (7) Patients receiving reservation treatment; (8) Patients with incomplete data.

2.4 Database collection and definition

•
Demographic and anthropometric characteristics: gender, age, weight, height, body mass index (BMI), BMI type (underweight, normal weight, overweight, or obesity).
•
Lifestyle: alcohol consumption (divided into never, no alcohol in the last year, less than once a month, monthly, weekly, and daily) and smoking (divided into non-smoker, active smoker, and ex-smoker).
•
Personal medical history: personal history of fracture, personal history of hip fracture, visual problem, hypertension (HT), diabetes mellitus (DM), lung disease (such as pneumonia, chronic obstructive pulmonary disease, and lung cancer), cardiovascular disease (such as coronary heart disease, myocardial infarction, and heart failure), cerebrovascular disease (such as cerebral infarction, Alzheimer’s disease and intracranial hemorrhage), gastrointestinal disease (such as gastric and duodenal ulcer, gastroesophageal reflux, gastric cancer and colorectal cancer), liver disease (such as liver cirrhosis, severe fatty liver and hepatocellular carcinoma), urinary tract diseases (such as urinary tract infection, kidney failure and lithiasis), anemia, hypothyroidism, osteoarthritis, rheumatoid arthritis, and pluripathology (divided into $<$ 3 and $\geqslant$ 3 comorbidities).
•
Characteristics related to injury, anesthesia and surgery: Pre-injury activity (bedridden, decreasing, moderately, or normal), falling place (at home or outdoors), fall time (day or night), causes of falling, type of fracture (femoral neck fracture or intertrochanteric fracture), fracture side (left or right), mode of anesthesia (general or regional), ASA (American Society of Anesthesiologists) grade (divided into I, II, III and IV), risk of ASA (low risk: I and II; high risk: III and IV), surgical delay time (hours), timing of surgical (divided into early $\leqslant$ 48 hours and late $\geqslant$ 48 hours), surgical date (weekdays or weekend), spend the weekend for surgery (yes or no), surgical procedure (osteosynthesis or prosthesis), surgical time (minutes), preoperative and postoperative hemoglobin (g/dl), blood transfusion.
•
Days and costs of hospitalization, and time of bed rest.
•
Harris Hip Score and one-year mortality.

2.5 Statistical analysis

SPSS22.0 statistical software was used for data analysis. The measurement data was expressed by mean $\pm$ standard deviation ( $\bar{x}\pm s$ ), and comparison between groups was by $t$ test. The count data was expressed as the occurrence rate $n$ (%), and the $X^{2}$ test was used for comparison. In all these statistical tests, significance is considered when $p<$ 0.05; very significant when $p<$ 0.01, and highly significant when $p<$ 0.001.

Table 1
Incidence, demographic and anthropometric characteristics between Spain and China

	Spain ( $n=$ 426)	China ( $n=$ 331)	Test T/ $X^{2}$	Value $P$
Incidence	239/10 ${}^{5}$	158/10 ${}^{5}$
Demographic characteristics
Sex			4.394	0.036 ${}^{*}$
Men	107 (25.1%)	106 (32.0%)
Woman	319 (74.9%)	225 (68.0%)
Age (years)	81.4 $\pm$ 9.3	76.0 $\pm$ 8.1	8.448	0.000 ${}^{***}$
Men	80.0 $\pm$ 10.2	73.3 $\pm$ 8.7	5.106	0.000 ${}^{***}$
Woman	81.9 $\pm$ 8.9	77.3 $\pm$ 7.5	6.614	0.000 ${}^{***}$
Anthropometric characteristics
Weight (Kg)	68.6 $\pm$ 12.7	58.6 $\pm$ 7.5	13.489	0.000 ${}^{***}$
Men	72.6 $\pm$ 11.1	67.0 $\pm$ 5.1	4.785	0.000 ${}^{***}$
Woman	67.3 $\pm$ 12.9	54.7 $\pm$ 4.7	15.932	0.000 ${}^{***}$
Height (m)	1.62 $\pm$ 0.09	1.61 $\pm$ 0.07	1.740	0.082
Men	1.70 $\pm$ 0.08	1.68 $\pm$ 0.05	2.699	0.008 ${}^{**}$
Woman	1.59 $\pm$ 0.07	1.58 $\pm$ 0.05	2.640	0.006 ${}^{**}$
BMI (Kg/m ${}^{2}$ )	26.1 $\pm$ 4.30	22.6 $\pm$ 1.95	14.987	0.000 ${}^{***}$
BMI type			195.247	0.000 ${}^{***}$
Under weight	6 (1.4%)	2 (0.6%)
Normal weight	166 (39.0%)	291 (87.9%)
Overweight	169 (39.6%)	34 (10.3%)
Obesity	85 (20.0%)	4 (1.2%)

Note: ${}^{*}p<$ 0.05; ${}^{**}p<$ 0.01; ${}^{***}p<$ 0.001.

3. Results

3.1 The incidence, demographic and anthropometric characteristics of the patients

A total of 757 patients were enrolled in this study, with 426 from HUVM and 331 from XDH. As a result, we concluded that the incidence of osteoporotic hip fractures in people over the age of 50 was 239 per 100,000 and 158 per 100,000 in the two cities, respectively. The proportion of Spanish women was higher than that of Chinese women, 319 (74.9%) vs. 225 (68.0%). The average ages of Spanish and Chinese patients were 81.4 $\pm$ 9.3 years (95% CI: 63.2–98.6) and 76.0 $\pm$ 8.08 years (95% CI: 60.3–91.7), respectively. The rest of the demographic and anthropometric characteristics are shown in Table 1.

3.2 Lifestyle

In general, the proportion of Spanish patients who drank and smoked was significantly higher than that of Chinese patients, particularly Spanish women. In both countries, there was no statistically significant difference between men (Table 2).

Table 2
Lifestyle of the Spanish and Chinese before the fracture

	Spain ( $n=$ 426)		China ( $n=$ 331)		Test $X^{2}$	Value $P$
Alcohol consumption					140.913	0.000 ${}^{***}$
Never	97	(22.8%)	215	(66. 0%)
Not in the last year	155	(36.4%)	51	(15.4%)
Less than once a month	125	(29.3%)	39	(11.8%)
Monthly	37	(8.7%)	22	(6.7%)
Weekly	10	(2.4%)	4	(1.2%)
Daily	2	(0.5%)	0	(0%)
Alcohol consumption in men					6.119	0.295
Never	12	(11.2%)	11	(10.4%)
Not in the last year	28	(26.2%)	37	(34.9%)
Less than once a month	31	(29.0%)	33	(31.1%)
Monthly	24	(22.4%)	21	(19.8%)
Weekly	10	(9.4%)	4	(3.8%)
Daily	2	(1.9%)	0	(0%)
Alcohol consumption in women					217.539	0.000 ${}^{***}$
Never	85	(26.7%)	204	(90.7%)
Not in the last year	127	(39.8%)	14	(6.2%)
Less than once a month	94	(29.5%)	6	(2.7%)
Monthly	13	(4.1%)	1	(0.4%)
Weekly	0		0
Daily	0		0
Smoking					18.739	0.000 ${}^{***}$
Does not smoke	225	(52.8%)	225	(68.0%)
Active smoker	55	(12.9%)	35	(10.6%)
Former smoker	146	(34.3%)	71	(21.5%)
Smoking in men					2.572	0.276
Does not smoke	11	(10.3%)	19	(17.9%)
Active smoker	33	(30.8%)	30	(28.3%)
Former smoker	63	(58.9%)	57	(53.8%)
Smoking in women					50.815	0.000 ${}^{***}$
Does not smoke	214	(67.1%)	209	(92.9%)
Active smoker	22	(6.9%)	3	(1.3%)
Former smoker	83	(26.0%)	13	(5.8%)

Note: ${}^{*}p<$ 0.05; ${}^{**}p<$ 0.01; ${}^{***}p<$ 0.001.

3.3 Personal medical history

Cardiovascular disease (75.5%), HT (70.7%), and osteoarthritis (54.0%) were the most common personal medical histories among Spanish patients. The Chinese patients, on the other hand, had anemia (70.1%), HT (48.9%), and osteoarthritis (45.3%). The proportion of Spanish patients with multiple pathologies ( $\geqslant$ 3) was significantly higher than that of China (69.3% vs. 58.6%), $p=$ 0.002. The summary of the comparison of personal medical history between Spain and China is detailed in Table 3.

Table 3
Comparison of personal medical history between Spain and China

	Spain ( $n=$ 426)		China ( $n=$ 331)		Test $X^{2}$	Value $P$
Personal history of fracture	129	(30.3%)	77	(23.3%)	4.633	0.031 ${}^{*}$
Personal history of hip fracture	47	(11.0%)	19	(5.7%)	6.556	0.010 ${}^{**}$
Visual impairment	103	(24.2%)	36	(10.9%)	21.988	0.000 ${}^{***}$
HT	301	(70.7%)	162	(48.9%)	36.975	0.000 ${}^{***}$
DM	149	(35.0%)	72	(21.8%)	15.759	0.000 ${}^{***}$
Lung disease	134	(31.5%)	100	(30.2%)	0.135	0.713
Cardiovascular disease	326	(75.5%)	142	(43.0%)	89.233	0.000 ${}^{***}$
Cerebrovascular disease	157	(36.8%)	130	(39.3%)	0.464	0.496
Gastrointestinal disease	48	(11.3%)	42	(12.7%)	0.359	0.549
Liver disease	16	(3.8%)	15	(4.5%)	0.285	0.593
Urinary disease	78	(18.3%)	34	(10.3%)	9.547	0.002 ${}^{**}$
Anemia	180	(42.3%)	232	(70.1%)	58.199	0.000 ${}^{***}$
Hypothyroidism	44	(10.3%)	18	(5.4%)	5.925	0.015 ${}^{*}$
Osteoarthritis	230	(54.0%)	150	(45.3%)	5.605	0.018 ${}^{*}$
Rheumatoid arthritis	82	(19.3%)	60	(18.1%)	0.154	0.695
Pluripathology					9.218	0.002 ${}^{**}$
$<$ 3	131	(30.8%)	137	(41.4%)
$\geqslant$ 3	295	(69.3%)	194	(58.6%)

Note: ${}^{*}p<$ 0.05; ${}^{**}p<$ 0.01; ${}^{***}p<$ 0.001. HT: Hypertension. DM: Diabetes mellitus.

Table 4

Characteristics related to injury, anesthesia and surgery of patients between Spain and China

	Spain ( $n=$ 426)		China ( $n=$ 331)		Test t/ $X^{2}$	Value $P$
Falling place					11.734	0.001 ${}^{***}$
At home	208	(48.8%)	203	(61.3%)
Outdoors	218	(51.2%)	128	(38.7%)
Fall time					5.910	0.015 ${}^{*}$
Day	327	(76.8%)	228	(68.9%)
Night	99	(23.2%)	103	(31.1%)
Activity level before the fracture					4.394	0.036 ${}^{*}$
Bedridden	4	(0.9%)	4	(1.2%)
Decreasing	211	(49.5%)	130	(39.3%)
Moderately	144	(33.8%)	138	(41.7%)
Normal	67	(15.7%)	59	(17.8%)
Causes of falling					10.671	0.031 ${}^{*}$
Knocked down	33	(7.8%)	23	(7.0%)
Get up or sit down	42	(9.9%)	44	(13.3%)
Go to the toilet or bathe	60	(14.1%)	34	(10.3%)
Falls while walking	263	(61.7%)	221	(66.8%)
Others	28	(6.6%)	9	(2.7%)
Type of fracture					1.959	0.162
Femoral neck	215	(50.5%)	184	(55.6%)
Intertrochanteric	211	(49.5%)	147	(44.4%)
Fracture side					2.974	0.085
Left	219	(51.4%)	191	(57.7%)
Right	207	(48.6%)	140	(42.3%)
Anesthesia mode					599.629	0.000 ${}^{***}$
General	14	(3.3%)	304	(91.8%)
Regional	412	(96.7%)	27	(8.2%)
ASA grade					65.976	0.000 ${}^{***}$
Grade I	2	(0.5%)	31	(9.4%)
Grade II	68	(16.0%)	101	(30.5%)
Grade III	297	(69.7%)	161	(48.6%)
Grade IV	59	(13.9%)	38	(11.5%)
ASA risk					49.957	0.000 ${}^{***}$
Low	72	(16.9%)	132	(39.9%)
High	354	(83.1%)	199	(60.1%)
Waiting time for surgery (h)	78.7 $\pm$ 48.2		60.7 $\pm$ 43.1		5.355	0.000 ${}^{***}$
Surgical delay time					12.535	0.000 ${}^{***}$
Early ( $\leqslant$ 48 hours)	154	(36.2%)	162	(48.9%)
Late ( $>$ 48 hours)	272	(63.9%)	169	(51.1%)
Surgical date					67.428	0.000 ${}^{***}$
Weekdays	426	(100%)	282	(85.2%)
Weekends	0	(0%)	49	(14.8%)
Pass the weekend to surgery	210	(49.3%)	62	(18.7%)	75.590	0.000 ${}^{***}$
Surgical methods					10.880	0.001 ${}^{***}$
Osteosynthesis	216	(50.7%)	128	(38.7%)
Prosthesis	210	(49.3%)	203	(61.3%)
Surgical methods for femoral neck fracture	4.28	0.039 ${}^{*}$
Osteosynthesis	5	(2.3%)	12	(6.9%)
Prosthesis	210	(97.7%)	172	(93.1%)
Surgical methods for intertrochanteric fracture					48.715	0.000 ${}^{***}$
Osteosynthesis	211	(100%)	116	(78.9%)
Prosthesis	0	(0%)	31	(21.1%)
Surgical time (minutes)	70.0 $\pm$ 15.8		70.4 $\pm$ 13.1		0.425	0.671
Preoperative hemoglobin (g/dL)	12.0 $\pm$ 1.8		11.4 $\pm$ 1.3		5.737	0.000 ${}^{***}$
Postoperative hemoglobin (g/dL)	9.4 $\pm$ 1.3		9.2 $\pm$ 0.5		3.559	0.000 ${}^{***}$
Blood transfusion	138	(30.1%)	139	(42.0%)	7.398	0.007 ${}^{*}$

Note: ${}^{*}p<$ 0.05; ${}^{**}p<$ 0.01; ${}^{***}p<$ 0.001.

3.4 Characteristics related to injury, anesthesia and surgery

As shown in Table 4, in the comparison of falls, there were statistical differences in the place of the fall, the time of the fall, and the cause of the fall. The pre-injury activity of China patients was better than that of Spain patients. There was no significant difference between the type of fracture and the side of the fracture. Statistical differences between the anesthesia method and the anesthesia risk were observed. In addition, the timing of surgery in Spain was significantly longer than that in China. In the comparison of surgical methods, the treatment methods used for different fracture types were different, and there were statistical differences. Regarding the operation time, no difference was observed between the two hospitals. Both before and after surgery, the average hemoglobin level of Spain patients was higher than that of China patients, $p=$ 0.000 and $p=$ 0.000, respectively. Therefore, more China patients received blood transfusion, 139 (42.0%) vs. 138 (30.1%), $p=$ 0.007.

Table 5
Days and costs of hospitalization, and time of bed rest between Spain and China

	Spain ( $n=$ 426)		China ( $n=$ 331)		Test $t$	Value $P$
Hospital stay (days)	9.2	$\pm$ 5.3	12.9	$\pm$ 3.3	8.592	0.000 ${}^{***}$
Time of bed rest (days)	20.0	$\pm$ 5.3	16.2	$\pm$ 8.2	2.831	0.005 ${}^{**}$
Cost of hospitalization (euros)	13.179	$\pm$ 1496	5.851	$\pm$ 686	256.934	0.000 ${}^{***}$
	Osteosynthesis		Prosthesis		Test $t$	Value $P$
Time of bed rest (days)	29.9	$\pm$ 19.3	8.7	$\pm$ 8.9	18.379	0.000 ${}^{**}$

Note: ${}^{*}p<$ 0.05; ${}^{**}p<$ 0.01; ${}^{***}p<$ 0.001.

Table 6

Harris Hip Score and mortality between Spain and China

	Spain ( $n=$ 426)	China ( $n=$ 331)	Test $t$	Value $P$
Harris Hip Score			2.454	0.484
Excellent	159 (39.3%)	131 (40.3%)
Good	184 (45.4%)	157 (48.3%)
Regular	48 (11.9%)	28 (8.6%)
Bad	14 (3.5%)	9 (2.8%)
Mortality within one year	81 (19.01%)	43 (12.99%)	4.934	0.026 ${}^{*}$

Note: ${}^{*}p<$ 0.05; ${}^{**}p<$ 0.01; ${}^{***}p<$ 0.001.

3.5 Days and costs of hospitalization, and time of bed rest

Compared with Chinese patients, Spanish patients had a shorter hospital stay (9.2 $\pm$ 5.3 (95% CI: 6.2–19.6) vs. 12.9 $\pm$ 3.3 (95% CI: 7.1–19.4) days), but the time of bed rest was longer in Spanish (20.0 $\pm$ 5.3 (95% CI: 9.6–30.4) vs. 16.2 $\pm$ 8.2 (95% CI: 4.6–31.2) days), $p=$ 0.000 and $p=$ 0.005, respectively. Furthermore, the time of bed rest with osteosynthesis was significantly longer than that with prosthesis (29.9 $\pm$ 19.3 (95% CI: 10.2–66.9) vs. 8.7 $\pm$ 8.9 (95% CI: 3.4–26.1) days), $p=$ 0.000. The average cost was 13,179 $\pm$ 1,496 (95% CI: 10,246–16,111) and 5,851 $\pm$ 686 (95% CI: 4,506–7,195) euros in Spain and China, respectively, $p=$ 0.000 (Table 5).

3.6 Harris Hip Score and mortality

In comparison to the Harris Hip Score, the excellent and good rates for Spanish and Chinese patients were 84.7% and 88.6%, $p=$ 0.484. During the one-year follow-up period, 81 cases (19.01%) died in Spain and 43 cases (12.99%) died in China, $p=$ 0.026. Among Chinese patients with intertrochanteric fractures, 31 received prostheses and had a 12.9% one-year mortality rate, while the remaining 116 received osteosynthesis and had a 22.4% mortality rate (Table 6).

4. Discussion

This article is the first study that compares the epidemiology of hip fractures in Spain and China. We discovered that the epidemiology of hip fractures varies due to differences in the two countries’ economies, medical levels, and cultural concepts by collecting clinical data on hip fracture patients treated in two large hospitals.

First, we discovered the disparity in incidence of osteoporotic hip fractures between Seville, Spain and Xi’an, China. The incidence rate in Seville over the age of 50 was approximately 239 per 100,000 inhabitants, which is consistent with the previous findings in the same city [8], with 228 per 100,000 inhabitants. In Xi’an, there was approximately 158 per 100,000 inhabitants. This is consistent with the findings of another study conducted in the same location [17], which was 153/10 ${}^{5}$ . It is also close to the results of a recent study involving 480 million people across the country [10], which was 149/10 ${}^{5}$ .

In terms of demographic characteristics, Spanish women have a higher proportion of hip fractures, accounting for about three-quarters, while Chinese women account for about two-thirds. This is consistent with the results of other reports [6, 18]. Second, we discovered that in most countries, the average age of onset of hip fractures is close to the country’s average life expectancy. For example, in 2019, the average life expectancy of Spain, China and Egypt was 82.8, 76.1 and 72.0 years, respectively [19]. In recent years, reports from these three countries show that the average age of hip fractures is 82.3, 77.1, and 70.8 years [10, 20, 21], respectively. Therefore, the difference in age of hip fracture is mainly related to life expectancy.

Regarding anthropometric characteristics, the height, weight and BMI of Spanish patients are significantly higher than those of Chinese patients. The first reason is genetic: the average height of Europeans is higher than that of East Asians [22]. Another reason could be that the birth and development of Chinese patients in this age group were born and developed in a period of war and poverty, resulting in their height and weight being lower than Spanish patients. In terms of overweight and obesity rates, however, Spanish patients outnumber Chinese patients, particularly women. A meta-analysis found that there is a correlation between BMI and bone mass, that is, the higher the BMI, the better the bone density, which is considered to be a protective factor for osteoporotic hip fractures, and put forward the viewpoint of increasing the BMI of the elderly to reduce the incidence of hip fractures [23]. However, from the study we conducted, the percentage of overweight and obese patients with hip fractures in Spain was close to 60%, which is significantly higher than the 47% of the normal population [24]. Perhaps this is because obese patients have less flexibility, are more likely to fall, and their excessive weight at the time of injury exerts more force, which offsets the better bone density [25]. In addition, the BMI level is negatively correlated with the postoperative rehabilitation effect of hip fractures, that is, the higher the BMI, the worse the postoperative functional rehabilitation [26]. Moreover, as we all know, obesity is also a risk factor for many diseases, such as cardiovascular and cerebrovascular diseases, arthritis and diabetes [27]. For these reasons, we believe that maintaining a normal BMI is the healthiest option, rather than increasing BMI to reduce the risk of hip fractures.

Many studies have shown that alcohol affects bone metabolism, not only inhibiting bone synthesis but also increasing bone desorption via direct and indirect pathways, resulting in osteopenia and osteoporosis and increasing the risk of fractures [28, 29]. In our comparative study, we found that the proportion of Spanish women drinking is significantly higher than that of Chinese women. Smoking has a number of negative consequences, one of which is low bone density. Furthermore, smoking is linked to an increased fracture risk in both men and women, as well as delayed fracture healing [30]. Based on Dimitris’ research, ex-smokers and active smokers have an increased risk of hip fractures when compared to never-smokers, but the longer they quit smoking, the lower the risk of fractures [31]. Therefore, the higher consumption of tobacco and alcohol by Spanish women may be one of the reasons why they account for a higher proportion of hip fractures than Chinese women.

Hip fracture patients over 65 years of age often have multiple personal medical histories. The internal homeostasis of the patient is altered by the hip fracture, which causes a continuous deterioration of his general condition. It is worth noting that 75% of patients die as a result of a comorbidity that existed prior to the injury, rather than the pathology of the hip fracture itself [32]. Yoon et al. have shown that dementia and DM have a significant effect on postoperative functional outcomes [33]. Anemia will increase hospital complications as well as hospitalization costs [34]. A meta-analysis shows that malignant tumors, lung disease, DM, and cardiovascular disease significantly increase the risk of death after hip fracture surgery [35]. Studies have shown that personal history of fracture is one of the major risk factors for hip fractures [36]. In addition, some studies have shown that having more than 3 common comorbidities are risk factors that lead to the death of patients in one year [37]. In this study, we have found that the proportion of patients with 3 or more types of comorbidities is significantly higher in Spain than in China. This is especially true in the case of visual problems, diabetes, hypertension, cardiovascular disease, a personal history of fracture, osteoporosis, and so on, which may be one of the reasons why the mortality rate of Spanish patients is higher than that of Chinese patients. In summary, the comorbidities of elderly patients with hip fractures are not only related to the increased risk of osteoporosis and falls, but also to the increased risk of postoperative hip fracture death. Therefore, active prevention and treatment of elderly comorbidities can reduce the incidence and mortality of hip fractures.

Falls are the leading cause of hip fractures, which have serious psychological consequences for patients, such as a fear of falling and a loss of self-confidence. Walking is one of the most common causes of falls. In this study, we discovered an intriguing phenomenon: while pre-fracture activity in Spanish patients is lower than in Chinese patients (50.4% in Spain have no or little activity, compared to 40.3% in China), more Spanish patients fell during the day and outside. For example, in Seville, there are lanes dedicated to wheelchairs on both sides of the street; there are no steps on the bus, and it is more convenient for the elderly on crutches to get on and off the bus, and there is a ramp for wheelchairs on the bus. Another reason may be that older people in Spain have a more open perception and are more willing to enjoy a free and better life outdoors. In contrast, in Xi’an, China, the details of public transportation facilities are not friendly enough. For example, there are steps for getting on and off the bus, which is inconvenient for the elderly. In addition, in China, due to the conservative and traditional perception, more elderly people spend their time on the sofa watching TV or on the rocking chair on the balcony. All of this explains the interesting results we got in this study.

The primary method of treatment for elderly hip fracture patients is surgery, which can significantly reduce mortality and achieve treatment benefits. In our study, there are significant differences in the choice of surgical methods for patients between the two countries. In femoral neck fractures, although most patients in both countries have received more prosthetic treatment, 12 cases of fractures in China have received osteosynthesis, while only 5 cases in Spain. The main reason for this is that Chinese patients are younger, and osteosynthesis with femoral head preservation is the preferred treatment. However, for intertrochanteric fractures, all Spanish patients received osteosynthesis, while 31 Chinese patients received prostheses. Studies have shown that the use of prosthesis for the treatment of unstable intertrochanteric fractures is significantly better than internal fixation (DHS or PFNA) in terms of walking time, postoperative complications, Harris Hip Score and mortality [38]. Among Chinese patients with intertrochanteric fractures, 31 patients who received prostheses had a one-year mortality rate of 12.9%, while the remaining 116 patients who received osteosynthesis had a mortality rate of 22.4%. This indicates that the prosthesis is a good therapeutic alternative for unstable intertrochanteric fractures. Therefore, Spanish orthopedic surgeons should also consider the choice of prosthesis for intertrochanteric fractures.

In addition, we discovered that Spanish patients had longer surgery wait times than Chinese patients. This is because there are many patients in Spain waiting for surgery on weekends, while 14.8% of Chinese patients undergo surgery on weekends. The main reason for this difference is the healthcare system and the medical environment. In fact, in Spain, except for emergencies, they only perform operations on working days, while in China, they are also undergoing intensive operations on Saturdays. In the medical environment, Chinese patients and their families are more aggressive to medical staff forcing the doctors to urgently perform the procedudres [39]. A number of studies have shown that surgical delay is an independent risk factor for postoperative death in patients with hip fractures, and early surgery can reduce perioperative complications and mortality [40, 41]. This may also be a reason for the higher mortality rate among Spanish patients.

In terms of anesthesia, XDH prefers general anesthesia in China, whereas HUVM in Spain prefers regional anesthesia. This difference was only observed in the two hospitals studied and does not reflect the two countries. In fact, our review of Chinese literature revealed [42], many Chinese hospitals use more regional anesthesia than general anesthesia. However, more research evidence shows that different anesthesia methods will not affect the complications and mortality of patients with hip fractures [43]. In the comparison of ASA classification, the high-risk ratio of Spanish patients is significantly higher than that of Chinese patients, indicating that the overall condition of Spanish patients is worse. The Wang’s study shows that the high risk of ASA is an independent risk factor for death from hip fracture within one year [44]. In our study, there are more Chinese elderly people suffering from anemia, and the preoperative hemoglobin is significantly lower than that of the Spanish. Studies have shown that the higher the BMI, the lower the possibility of anemia [34], which may be the reason why the elderly in China are more likely to suffer from anemia. Therefore, more Chinese patients have to receive blood transfusions.

Patients with hip fractures have longer hospital stays than patients with other closed fractures because they have more comorbidities, longer surgical delays, and other postoperative complications [45]. In this study, the average hospital stay of Chinese patients is longer than that of Spanish patients. The main reason for this is that some Chinese patients do not have clinics or hospitals close to their homes, making it difficult for them to change dressings and remove sutures from wounds after surgery. However, a longer hospital stay may be beneficial to the patient. A South Korean study found that elderly patients with hip fractures who were hospitalized for less than 10 days had a higher mortality rate within one year after discharge [46]. Reducing the length of hospital stay entails shortening the time it takes for patients to receive nursing care in the hospital following surgery, as well as shortening the time it takes for a comprehensive assessment of the patient’s medical condition during this time. In fact, the amount of time spent in bed is directly related to the patient’s prognosis. Time spent in bed increases the risk of pressure ulcers, pulmonary infections, venous thrombosis, muscle atrophy, and cardiovascular complications [47]. In this study, the average number of days of bed rest for Chinese patients was significantly lower than that of Spanish patients, and the bed rest time of prosthesis treatment was significantly shorter than that of osteosynthesis treatment.

Regarding hospitalization costs, Spanish patients are significantly higher than Chinese patients. However, due to price and purchasing power differences, we must compare them in a different way. We believe that the average wage is an appropriate method in this case. For example, the average annual income of residents of Seville in 2019 was 16,271 euros [48], while in Xi’an it was 58,080 RMB, approximately 7,260 euros [49]. In other words, the hospitalization costs for hip fractures in the two countries are relatively similar, about 10 months’ salary. Finally, we must point out that as the elderly population increases, prevention has become the best strategy to reduce the cost of hip fractures, thereby reducing the high costs borne by the health system and families.

Because of the high mortality and disability rates, hip fracture is known as the “last fracture in life.” The one-year mortality rate following a hip fracture is 15% to 40%, which is 3 to 4 times higher than the general population [50, 51]. In this study we have seen one-year mortality rates of 19.01% in Spain and 12.99% in China. A recent meta-analysis carried out in China showed that the one-year mortality rate was 13.96% [12]. In Spain, a study using national data showed that the annual mortality rate for men and women under 80 years of age is 22%; that of women over this age was 25.2%, while that of men was 30.1% [52]. Based on these data, we can conclude that the one-year mortality rate of hip fracture patients in China is lower than that of Spain.

4.1 Strengths and limitations

This is the first study comparing the epidemiology and mortality rates of hip fractures in Spain and China. The following are the benefits of this research. First, the two hospitals chosen, HUVM in Seville and XDH in Xi’an, are large-scale comprehensive tertiary hospitals that are typical of hospitals in both countries. Secondly, the sample size is large, with a total of 757 patients included. In addition, the study includes a wide range of variables, such as pre-injury status, lifestyle and comorbidities, and the content of the comparison is very detailed. However, some limitations have affected the research: each hospital has its own culture and environment, and the data may not be representative of other hospitals in the two countries. Another considerable limitation of this study is the follow-up method. We cannot obtain information about patients going to other hospitals after they are discharged, especially for Chinese patients, because the electronic medical record systems between hospitals are not connected to the Internet. As a result, some of the Chinese patients’ death information was obtained by calling their family members, which may have resulted in the loss of some important death-related information. Moreover, for the identification of osteoporotic hip fractures, we rely on age greater than 50 years and low energy trauma, rather than dual energy X-ray absorptiometry. In addition, the risk factors that affect the death of patients are an important research topic, but they were not carried out in this study. Finally, this is a retrospective study.

5. Conclusion

Our study found significant epidemiological differences between hip fracture patients in Seville, Spain and Xi’an, China. Gender, age, injury location, comorbidities, and other differences cannot be changed by admonishing patients or selecting treatment methods. We can, however, narrow the gap by advising patients to maintain a normal BMI, develop a healthy lifestyle, and select appropriate surgical methods to provide patients with a better foundation for rehabilitation and reduce mortality.

Footnotes

Conflict of interest

None to report.

Funding

None to report.

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The epidemiological status of osteoporotic hip fractures: A bicentric comparative and retrospective study

Abstract

BACKGROUND:

OBJECTIVE:

METHOD:

RESULTS:

CONCLUSIONS:

Keywords

1. Introduction

2. Materials and methods

2.1 Patients

2.2 Profiles of the two hospitals

2.3 Inclusion and exclusion criteria

2.4 Database collection and definition

Table 1 Incidence, demographic and anthropometric characteristics between Spain and China

3.1 The incidence, demographic and anthropometric characteristics of the patients

3.2 Lifestyle

Table 2 Lifestyle of the Spanish and Chinese before the fracture

Table 3 Comparison of personal medical history between Spain and China

Table 5 Days and costs of hospitalization, and time of bed rest between Spain and China

3.6 Harris Hip Score and mortality

4. Discussion

4.1 Strengths and limitations

5. Conclusion

Footnotes

Conflict of interest

Funding

References

Table 1
Incidence, demographic and anthropometric characteristics between Spain and China

Table 2
Lifestyle of the Spanish and Chinese before the fracture

Table 3
Comparison of personal medical history between Spain and China

Table 5
Days and costs of hospitalization, and time of bed rest between Spain and China