Abstract

Proceedings of the 9th Fragility Fracture Network Congress (Delivered virtually on 28-30Sep21)

P001: Effect of Early Postoperative Administration of Bisphosphonates on Healing of Osteoporotic Fractures of the Distal Radius

D. Begkas ^*1 , S. T. Chatzopoulos ¹ , G. Geogrgiadis ² , A. Balanika ³ , and A. Pastroudis ¹

¹ 6th Orthopaedic Department and Osteoporosis Department,, ² 4th Orthopaedic Department and Osteoporosis Department, ³ Deparment of Computed Tomography and Department of Osteoporosis, Asclepieion Voulas General Hospital, Athens, Greece

Introduction: Osteoporosis is often not clinically recognized until a fracture occurs. People who have had an osteoporotic fracture are at increased risk for future fractures. Immediate initiation of osteoporosis treatment is critical to reducing the rate of future fractures. Bisphosphonates are the most common class of drugs for the prevention and treatment of osteoporosis. Many doctors are reluctant to start bisphosphonate application in the acute period after a fracture. Their concerns include interference with bone remodeling necessary for successful fracture healing, which could cause increased rates of non-union, malunion, and refracture. The purpose of this study was to evaluate the effect of early postoperative administration of bisphosphonates on healing of osteoporotic fractures of the distal radius. Methods: Between 2011 and 2017, 120 patients (87 females and 33 males) with a mean age of 68.4 (57–82) who suffered from osteoporotic fractures of the distal radius, were surgically treated in our clinic using open reduction and internal fixation (locking plates and screws). All of them received postoperative treatment with bisphosphonates (Alendronate 70 mg/week or Risedronate 35 mg/week). In 62 patients (group A) the bisphosphonate treatment was administered immediately (within 2–3 days postoperatively), while in the remaining 58 patients (group B) was delayed (3 months postoperatively). Treatment results on fracture healing for each group were based on clinical/functional (pain or tenderness, grip strength, wrist range of motion, Quick-Disabilities of the Arm, Shoulder and Hand Score – QDASHS) and radiographic (anteroposterior and lateral X-rays – radiological fracture healing time) criteria. Results: The mean follow-up duration was 38.4 (24–60) months. Radiologically, the mean fracture healing time for group A was 3.1 (2.5–4.5) months and for group B 2.9 (2.5–4) months (P = 0.07). After the sixth post-operative month, there was no significant difference between the two groups in improving pain or tenderness in the fracture area, grip strength, range of motion and QDASHS. Conclusion: Early administration of bisphosphonates after surgically treated osteoporotic radial fractures does not appear to significantly affect their radiological healing time, as well as the final clinical/functional outcome.

P002: Effect of Preoperative Bisphosphonate Administration on the Healing of Intertrochanteric Femoral Fractures After Intramedullary Nailing

D. Begkas ^*1 , S. T. Chatzopoulos ¹ , A. Balanika ² , G. Geogrgiadis ³ , and A. Pastroudis ¹

¹ 6th Orthopaedic Department and Osteoporosis Department, ² Deparment of Computed Tomography and Department of Osteoporosis, ³ 4th Orthopaedic Department and Osteoporosis Department, Asclepieion Voulas General Hospital, Athens, Greece

Introduction: Bisphosphonates (BPs) are the most commonly used antiresorptive osteoporosis medications. However, there have been concerns about their negative effects on fracture healing as they may inhibit bone remodeling and delay fracture union due to osteoclast inhibition. The purpose of this study was to investigate the effects on fracture healing of BP administration before intramedullary nailing (IMN) of intertrochanteric femoral fractures (IFF). Methods: We retrospectively analyzed data from 350 patients who underwent IMN for osteoporotic IFF during the period between 2013 and 2018. Patients were divided into two groups (A and B). Group A (n = 125) included those who had previously received BPs for at least 3 months prior to IMN. Group B (n = 225) included all patients who had not received BPs. Evaluation of fracture healing outcomes in both groups was based on radiological (callus formation in plain radiographs 3, 6 and 12 months after IMN) and clinical (change in Koval score before and 1 year after IMN) criteria. Results: Three, 6 and 12 months after IMN, fracture healing was achieved in 72.8% (91/125), 90.4% (113/125) and 92.8.6% (116/125) of patients, respectively, in group A and in 90.7% (204/225), 94.2 (212/225) and in 96.9% (218/225) of patients, respectively, in group B. The change in Koval score was of the order of 0.1 (from 1.2 before IMN to 1.1 one year after IMN; P = 0.69). Multivariable logistic regression analysis revealed that a history of BP administration was associated with an increased risk of delayed union at 3 months postoperatively (P = 0.016). Conclusion: Preoperative BP administration was associated with a reduced rate of fracture healing 3 months after IMN, compared with patients who had not received BPs. Therefore, patients who have previously been treated with BPs should leave walking aids with extreme caution and gradually and very carefully switch to full weight bearing during the early postoperative period.

P003: Cement in Proximal Humerus Fracture

M. Molinedo ^*1 , P. Vicente ¹ , I. Berasategi ¹ , M. P. Molinedo ² , and N. Cartiel ¹

¹ Hospital San Jorge, Huesca, ² Hospital Clinico Lozano Blesa, Zaragoza, Spain

Introduction: Fractures of the proximal limb of the humerus represent 4–6% of all fractures in adults and are the second most frequent in the upper limb. They are closely linked to osteoporosis, being more frequent in the elderly, and especially in women. In older patients, they can benefit from different therapeutic options ranging from conservative treatment to arthroplasty. Methods: Two cases are prospectively reviewed and followed for 1 year. CASE 1: 74-year-old patient with Neer's three-fragment fracture after a fall operated with a blocked plate augmented in one of its screws plus suture of the greater tuberosity. CASE 2: 76-year-old patient with Neer's three-fragment fracture that was operated with a locked plate in one of her screws with a greater tuberosity suture and two interference screws. Surgery is performed under general anesthesia in both cases, immobilization in a sling is performed for 3 weeks and subsequent rehabilitation and serial radiographic controls at each consultation. Results: In both cases, consolidation occurred before six months, with no loss of reduction being observed. In both cases, there was no residual pain, they recovered their basic activities of daily living and there was no penetration of the cement into the joint cavity. In addition, active joint balance was measured, observing the following results: 95º and 100º m abduction, 100 and 105º antepulsion, 50 and 60º external rotation; and finally the internal rotation is L4 AND L5. Conclusion: Proximal humerus fractures in osteoporotic patients continue to be a current problem, without a clear solution. According to the literature, with the use of locked plates without augmentation, fixation failure and intra-articular screw penetration can reach rates of up to 19% and 8%, respectively. Surgical techniques that add implant augmentation represent an appropriate option to improve the biomechanical characteristics of our fixation, maintaining the reduction and, therefore, allowing the early start of rehabilitation, with better functional results and clinical benefits for the patient.

P004: Can We Still Use Hemiarthroplasty for Treating Femoral Neck Fractures in Patients With Neuromuscular Conditions?

M. Awadallah ^*1 , J. Ong ¹ , N. Kumar ¹ , P. Rajata ¹ , and M. Parker ¹

¹ Trauma and Orthopaedics Department, North West Anglia NHS Foundation Trust, Peterborough, UK

Introduction: Dislocation of a hip hemiarthroplasty is a devastating complication with a high mortality rate in elderly patients. Previous studies, despite their limited evidence, have suggested a higher risk of dislocation in patients with dementia or neuromuscular conditions. In this study, we have reviewed our larger cohort of patients to identify whether there is any association between neuromuscular disorders and prosthetic dislocation in patients treated with hip hemiarthroplasty for femoral neck fractures. Methods: Our study is a retrospective analysis of data collected over 34 years for patients with intracapsular neck of femur fracture who underwent hip hemiarthroplasty. The study population is composed of four groups: patients with no neuromuscular disorders, patients with Parkinson’s disease, patients with previous stroke, and patients with dementia. Results: A total of 3827 patients were treated with hip hemiarthroplasty. For the 3371 patients with no neuromuscular condition (Group I) the dislocation rate was 1.1%. 219 patients had Parkinsonism (Group II) with a dislocation rate of 3.2%, 104 patients had a previous stroke with weakness on the fracture side with a dislocation rate of 1.0% (Group III), and 984 patients had severe dementia with a dislocation rate of 1.8% (Group IV). The increased dislocation rate for those with Parkinson’s disease was statistically significant (P = 0.02) while none of the other neuromuscular conditions were statistically significant. Conclusion: Our study demonstrates an increased risk of dislocation after hemiarthroplasty for patients with Parkinson’s disease in comparison to other groups. Hip hemiarthroplasty for femoral neck fracture is not contraindicated in patients with neuromuscular disorders and can still be a valid option for treating patients with Parkinson’s disease despite a slightly increased dislocation risk.

P005: Analgesia Provision in Femoral Neck and Fragility Fracture Patients

A. Rapson ^*1 , H. Naqvi ² , and J. Taylor ³

¹ Trauma & Orthopaedics, ² Geriatric Medicine, Sandwell and West Birmingham Hospitals NHS Trust, ³ University of Birmingham, Birmingham, UK

Introduction: Throughout the UK, over 70000 patients present with fractured neck of femurs (#NOF) every year. Often occurring due to fragility fractures in elderly patients with multiple co-morbidities, #NOFs are associated with significant morbidity and mortality, and are the single largest reason for admission to an orthopaedic ward. The establishment of dedicated orthogeriatric departments have helped optimally manage #NOF patients, however with many patients waiting over 24 hours for definitive operative management or orthogeriatric assessment, prompt and effective analgesia prescribing is essential for optimal patient care. We aimed to identify where delays in providing analgesia to #NOF patients lay in order to improve patient care, with recommendations for improvement made at departmental meetings prior to re-audit. Methods: Retrospective analysis of the hospital records of patients presenting with #NOF, distal femoral fractures and peri-prosthetic between 1st September 2020 and 31st October 2020, assessing for time of presentation, #NOF confirmation, analgesia prescription and analgesia administration. By time of audit presentation, two further cycles will be completed with targeted improvements made between each cycle. Results: 65 eligible patients were identified in the initial cycle. #NOF patients waited a mean 6 hours from admission for oral analgesia administration, with 12% receiving no pre-operative analgesia at all. Half (52%) received fascia iliaca block. 83% were prescribed PRN morphine, however less than 10% anti-emetics. These findings were highlighted locally at orthopaedic and emergency department meetings in January/February 2021, with plan to re-audit with two further cycles after recommendations later in 2021. Conclusion: Many #NOF patients are not receiving adequate analgesia before orthogeriatric assessment, decreasing the quality of patient care. Additionally, inadequate pain control can increase risk of or exacerbate delirium which can be distressing for patients and result in long term sequalae. Targeted improvements based on these initial findings were disseminated through hospital departments to optimise patient care prior to re-audit.

P006: Out of Hospital Opiate Prescription in Hip Fracture Patients in a District General Hospital in England

D. Mistry ^*1 , S. Kanabar ¹ , A. Kumar ¹ , R. Smith ¹ , H. Naeem ¹ , F. Zahir ¹ , Y. Gurung ¹ , and A. Chatterjee ¹

¹ Royal Berkshire Hospital, Reading, UK

Introduction: Following a serious incident, a Quality Improvement Project (QIP) was launched to evaluate opiate prescriptions in Hip Fracture patients in the Out of Hospital (OOH) and Emergency Department (ED) settings. The aim of this was to reduce harm and improve surgical outcomes. Methods: One hundred consecutive patients admitted to the Royal Berkshire Hospital, Reading, Berkshire, UK, were identified from National Hip Fracture Database between January and August 2019. Medical records were reviewed in both care settings, identifying dose and route of morphine prescriptions in comparison to pain scores, body weight and renal function. Outcomes measured include constipation, acute kidney injury, respiratory compromise, and mortality. Statistical tests (t-test and chi square) were used to discern significance. Results: 74% were female and the average age was 84. Morphine doses given OOH ranged from 2 to 40mg, in comparison to 2.5–20 mg in ED. 18% of patients suffered from respiratory depression within 48 hours of their admission with a further 7% suffering from an acute kidney injury. Following the first cycle, results were disseminated to paramedics and at governance meetings (ED, Trauma & Orthopaedic and Hip Fracture). Teaching was undertaken and a poster designed to reduce harm by appropriate opiate prescribing. A second cycle evaluated 30 consecutive Hip Fracture patients in July 2020. After these interventions, OOH morphine doses ranged between 5 and 10 mg, a reduction of 75% of maximum dose, with increased use of adjuvants as guided by the WHO pain ladder. No adverse outcomes were noted within 48 hours of admission. Conclusion: Opiate based analgesia forms a key component of Hip Fracture management. If prescribed inappropriately, this can lead to respiratory depression, nephrotoxicity, and delayed recovery. OOH opiate prescription should be tailored to individual patients according to their age, body weight, renal function. Whilst controlling significant pain in the OOH setting is crucial, currently there is no guidance for opiate prescribing, so a pragmatic approach should be adopted to reduce harm and improve outcomes. As part of this QIP, a guideline has been written and published to aid inpatient opiate prescription in older patients.

P007: Between Heaven and Hell – Experiences of Preoperative Pain and Pain Management Among Patients With Hip Fracture

A. Unneby ^*1 , B. Olofsson ² , Y. Gustafsson ³ , and B.-M. Lindgren ⁴

¹ Department of Nursing and Department of Surgical and Perioperative Science Orthopedics, ² Department of Nursing, ³ Department of Community Medicine and Rehabilitation, Geriatric Medicine,, ⁴ Nursing, Department of Nursing, Umeå, Sweden

Introduction: Hip fracture is a common and serious consequence from a fall among old people. Preoperative pain is common and often severe among patients suffering hip fracture. Opioids are usually used but have many side effects. One alternative is a femoral nerve block (FNB). It has been shown to reduce pain and lower the needs for opioids. However, to our knowledge no study has explored qualitatively how patients with hip fracture experiences the treatment with FNB. The aim of this study was to explore experiences of preoperative pain and pain management among patients with hip fracture who had received a femoral nerve block. Methods: A qualitative design with semi-structured interviews (n = 23) were conducted 2–6 days after surgery. Inclusion criteria were 70 years or older Swedish speaking patients with hip fracture admitted to the Orthopedic Ward, treated with femoral nerve block before nursing actions. Data was analyzed with qualitative content analysis. Results: Our result revealed one theme; hovering between and hell with five sub-themes; experiencing memory loss due to remember the pain and pain management and how the pain were described to be no pain, to worst pain and everything in between; they were dealing with pain in an own way; felt dependent to staff´s willingness to relive pain; and that pain management could be lifesaving and a near death experience. Conclusion: The experience of pain and pain management was described as hovering between heaven and hell. We conclude that pain management should be person-centered independent on which pain management given to achieve well managed pain. 

P008: The Subtrochanteric Fracture in Our Hospital: A Five-Year Study

I. Berasategi ^*1 , M. Molinedo Quilez ¹ , N. Cartiel Marco ¹ , M. Sancho Rodrigo ¹ , B. Refoyo Matellán ² , and P. Vicente Alonso de Armiño ¹

¹ Salud. San Jorge,, ² San Jorge. Huesca, Huesca, Spain

Introduction: When the fracture line is between the lesser trochanter and 5cm distal to it, the fracture is called subtrochanteric. They are quite frequent fractures, being approximately 15% of proximal femur fractures. They present a bimodal age distribution, occurring in up to three-quarters of the population over 75 years, mostly women and secondary to low energy trauma. The objective of this study is to describe the cases of subtrochanteric fracture in our hospital in last years and to compare the results to those in the literature. Methods: A retrospective descriptive study of 137 patients who suffered a subtrochanteric femur fracture was carried out. Age, sex, injury mechanism, type of fracture, previous and subsequent functionality, need for transfusions after surgery, treatment for subsequent osteoporosis, and percentage of death have been analyzed. Results: 27% of the patients were men and 73% women, with a mean age of 80.2 years (30–99 years). Undoubtedly, the most frequent injury mechanism has been accidental fall, being responsible for more than 89% of fractures. Based on the Seinsheimer classification, 2.2% of the fractures were not displaced, 85.13% had 2 or 3 fragments, 7% were comminute, and 11.9% were persubtrochanteric fractures. After the surgical intervention, 64.8% of the patients required transfusion of at least 1 packed red blood cells. An improvement is observed in terms of progressive functionality, going from no ambulation to ambulation in the neighborhood at one year of follow-up, according to the FAC scale. At 3 years, the percentage of death from any cause is 29%. Conclusion: In our series, in agreement with the majority of the current literature on subtrochanteric fractures, fractures are more frequent in women, secondary to low-energy trauma, with significant deterioration and the need for frequent transfusions, but with a satisfactory evolution after one year of evolution.

P009: Mortality Following Periprosthetic Fractures of the Femur: A Retrospective Analysis of the Risk Factors

C. Low ^*1 , A. Brunt ² , J. Jeyakumar ² , A. Hall ² , P. Walmsley ² , A. Ballantyne ² , and A. Akhtar ²

¹ School of Medicine, University of St Andrews, St Andrews, ² Trauma and Orthopaedics Department, Victoria Hospital NHS Fife, Kirkcaldy, UK

Introduction: As the number of arthroplasty procedures being performed continues to escalate, due to the combined effect of the ageing population and expanding indications for arthroplasty procedures to the younger population, a concomitant rise in complications such as periprosthetic fractures could be observed in many countries, including the UK. Periprosthetic fractures are complex injuries, and their treatment is often physiologically demanding for the already frail and elderly patient, and thus, periprosthetic fractures are often associated with high mortality risks. Whilst the amount of research and data published has increased, following the noticeably rising number of periprosthetic fractures, there is still a general lack of research conducted on the elderly population of Scotland. Therefore, this retrospective cohort study aimed to investigate the mortality rates for patients sustaining periprosthetic fractures of the femur and to evaluate any associated risk factors. Methods: Routine clinical data were collected from a hospital located in Fife, Scotland, and analysed. Altogether, 35 patients with a periprosthetic femoral fracture around a total hip arthroplasty, or hip hemiarthroplasty, or total knee arthroplasty, were retrospectively analysed. Mortality rates and risk factors were tested for significance using chi-square tests and t-tests. Results: Between April 2017 and December 2019, the overall mortality for periprosthetic fractures of the femur was 34.29%. Advanced age, female gender, and shorter lengths of hospital stay were some of the risk factors identified in this study that could potentially contribute to higher post-fracture mortality risks. Conclusion: The findings of our study indicate that the mortality rates for periprosthetic fractures are significant, even when only data spanning over two years were collected. The risk factors for mortality identified and evaluated in this study should be carefully considered by orthopaedic surgeons during fracture management, so that patient outcome can be optimised, and mortality risks reduced.

P010: Surgical Treatment of Subtrochanteric Fractures on the Femur

I. Berasategi ^*1 , M. Molinedo Quilez ¹ , N. Cartiel Marco ¹ , M. Sancho Rodrigo ¹ , B. Refoyo Matellán ¹ , and P. Vicente Alonso de Armiño ¹

¹ Salud. San Jorge, Huesca, Spain

Introduction: Over the years, the conservative management of subtrochanteric fractures has been rejected, due to the long periods of bedridden needed with traction and its secondary complications, so that currently the gold standard is the surgical choice. The objective of this study is to describe the surgical management of fractures in our hospital in recent years and to compare the results to those in the literature. Methods: A retrospective descriptive study of 137 patients with subtrochanteric femur fracture was carried out, all of whom underwent surgery. The delay until the day of the intervention, the type of anesthesia performed, the type of implant used for osteosynthesis, the need for cerclage and the time of surgery were analyzed. Results: The mean delay time to surgery was 3.18 days (from 0 to 7 days). The average duration of the intervention according to the nursing staff was about 112.63 minutes (form 50 to 205 minutes), compared to the 70 minutes (from 25 to 150 minutes) according to the surgeons. In 63.8% of the cases, the intervention was performed under spinal anesthesia. In all cases, osteosynthesis of the fracture was carried out by intramedullary nailing, varying the type and length of the material (48.52% long nails; 51.47% short nails), performing cerclage of the fracture in 16, 9% of the cases. Conclusion: In accordance with the bibliography consulted, surgical treatment of subtrochanteric fractures is performed, regardless of age or injury mechanism, anterograde intramedullary nailing is the gold standard nowadays.

P011: Blood Transfusion After Surgical Intervention of a Subtrocanteric Fracture

I. Berasategi ^*1 , M. Molinedo Quílez ¹ , N. Cartiel Marco ¹ , M. Sancho Rodrigo ¹ , and P. Vicente Alonso de Armiño ¹

¹ Salud. San Jorge, Huesca, Spain

Introduction: Hip fractures in general, and particularly subtrochanteric fractures, have an associated risk that is the blood loss associated with both the fracture and the perioperative period, considering that on average up to 3 units of blood are lost. This loss is prevented with the correct choice of osteosynthesis material and the reduction of surgical time. However, one of the most frequent postsurgical requirements is blood transfusion. The objective of this study is to estimate the approximate blood loss and analyze its relationship with the time of surgical intervention. Methods: An observational, analytical and retrospective study of 137 patients surgically treated for subtrochanteric femur fracture was carried out, analyzing the associated blood loss (the hemoglobin value is taken as reference) and the required transfusions. Results: The mean pre-surgical hemoglobin value was 127.26 (88–165), with an approximate decrease of 37.7 in relation to surgery (mean postoperative hemoglobin value of 89.56 (8–128)). Only the 35.2% of the patients have been exempt from blood transfusion, with 50% of the patients requiring 2 or more blood concentrates. A statistically significant relationship has been demonstrated that those patients with a longer surgical time (27.72 minutes more than surgery) require the transfusion of up to 3 blood concentrates compared to those who have not received a transfusion. Conclusion: Blood loss associated with this type of fractures and its surgical treatment leads to blood transfusion in approximately 50% of cases.

P012: Differences in Consolidation After Surgical Treatment of Femoral Subtrochanteric Fractures

I. Berasategi ^*1 , M. Molinedo Quílez ¹ , N. Cartiel Marco ¹ , M. Sancho Rodrigo ¹ , P. Vicente Alonso de Armiño ¹

¹ Salud. San Jorge, Huesca, Spain

Introduction: The most usual complication in relation with the subtrochanteric fractures of de proximal femur is the consolidation in varus. Even though it is much more frequent when treating the fracture with an extramedullary device, the fracture itself or even the patient can lead to problems in consolidation. The objective of this study is to analyse the results in terms of consolidation after a subtrochanteric fracture. Methods: It was carried out an observational, analytic and retrospective study of 137 patients suffering subtrochanteric fracture and has been analysed the consolidation and certain characteristics that may have influenced in the results, such us, osteoporotic treatment, the osteosynthesis device used or the need for cerclage of the fracture. Results: The 82.5% of the fractures have healed after one year of follow-up, regardless of the type of fracture in question (80% of Seinheimer type II, 82.8% of type III, 77.8% of type V). The 20.2% of well consolidated fractures had cerclage, but it must be said that 100% of the fractures with cerclage have healed (statistically significant results). In the group of patients taking with calcium and vitamin D, 78.6% of them consolidated, of those taking bisphosphonates 77.8%, of those taking denosumab (Prolia®) 100% and in those taking teriparatide (Forsteo®) 75%. The mean RUSH SCORE was 27.13 (14–30), with a standard deviation of 2.75, showing a higher RUSH SCORE in patients treated with teriparatide (mean 27.69) and in type V fractures of Seinsheimer (mean 29.10). Conclusion: In our series, no significant differences were seen in terms of fracture consolidation depending on the implanted osteosynthesis device, but certain differences were observed depending on the type of fracture, onwards osteoporotic treatment and the implantation or not of cerclage.

P013: Assessment of Functionality in Patients with Subtrocanteric Fractures After Surgical Treatment

I. Berasategi ^*1,1 , M. Molinedo Quílez ¹ , N. Cartiel Marco ¹ , M. Sancho Rodrigo ¹ , and P. Vicente Alonso de Armiño ¹

¹ Salud. San Jorge, Huesca, Spain

Introduction: The main objective about the surgical treatment of femoral fractures is not only the healing of the fracture, but to do it as anatomically and functionally as possible to ensure early recovery and the previous ambulation. The cognitive status and the implant used are important factors to take into account. Ideally, the patient should achieve ambulation as soon as possible, but it depends on the collaboration of the patient and the stability of the fracture, among others. The objective of the study is to estimate the functionality of the patient one year after the fracture, analyzing the type of material implanted, the quality of previous ambulation and the discharge period performed after the intervention. Methods: A retrospective descriptive and analytical observational study of 137 patients with subtrochanteric femur fracture was carried out, all of them surgically treated. The functional status of the patient was assessed by analyzing previous ambulation, the type of material implanted and the rehabilitation type carried out. Results: After one year follow-up, 79.8% of the patients were able to walk, of which 52.7% had a long nail implanted, 76.7% of them had remained unloaded during the first month and almost a half of them walked independently before the fracture. The mean decrease in the Barthel scale during admission was 46.2 points and in the Harris Hip Scale it was 4.973, regardless of the osteosynthesis material used, previous ambulation or the period of unloading performed in the postoperative period. Regarding the FAC scale, we found slightly better results in the cases of long nail, with cerclage, having performed a short discharge period, and in patients with previous autonomous ambulation. Conclusion: In our series, the most satisfactory results are in those patients operated on with a long nail with cerclage of the fracture focus and those who have been unloaded for some time and with previous autonomous ambulation, without the need for technical aids.

P014: Death Rate Associated to Subtrochanteric Fractures of the Proximal Femur

I. Berasategi ^*1 , M. Molinedo Quilez ¹ , N. Cartiel Marco ¹ , M. Sancho Rodrigo ¹ , B. Refoyo Matellán ¹ , and P. Vicente Alonso de Armiño ¹

¹ Salud. San Jorge, Huesca, Spain

Introduction: Morbidity and mortality associated to proximal femur fracture has up to 30% mortality during the first year after the fracture and up to 5% in-hospital mortality, according to series. The possibility that early surgery in the first 48 hours is a preventive measure has been proposed in several studies, although it is still in question. The objective of the study is to analyze the cases of death associated to subtrochanteric fracture of the proximal femur in our hospital. Methods: A retrospective descriptive and analytical observational study of 137 patients with subtrochanteric femur fracture was carried out, all of them surgically treated. The death rate and its relationship with the time of surgical intervention, functional status according to the Barthel scale and the Harris Hip score have been analyzed. Results: We found a 29% overall mortality. It has been observed in those who survived a longer surgery time than in those who did not. Although the decline in the Barthel scale is similar between the groups, both the value of this scale at admission and discharge are lower in the group of the deceased (45,461 vs 57,809). We obtain similar results in the Harris Hip Scale, with a mean value per year of 85.37 in the group of survivors compared to 70.34 in the group of the deceased. The delay time until surgical intervention has not shown a higher mortality in patients, although it must be taken into account that the average days of delay until surgery in our hospital is above the recommended 48 hours. Conclusion: Our series shows a higher mortality associated to subtrochanteric hip fracture, observing better results in those patients with a higher functional status.

P015: Waiting More Than 24 Hours for Hip Fracture Surgery Is Associated With Increased Risk of Atrial Fibrillation and Congestive Heart Failure – A Nationwide Cohort Study Using the Register Rikshöft

K. Greve ^*1,2 , S. Ek ³ , E. Bartha ^1,2 , K. Modig ³ , and M. Hedström ^2,4

¹ Perioperative Medicine and Intensive Care (PMI), Karolinska University Hospital, ² Clinical Science, Intervention and Technology (CLINTEC), ³ Environmental Medicine (IMM), Karolinska institutet, ⁴ Trauma and Reparative Medicine Theme (TRM), Karolinska University Hospital, Stockholm, Sweden

Introduction: Hip fracture is a common injury among older people and is associated with increased risk of morbidity and death. Prolonged waiting for hip fracture surgery is considered detrimental, but recommendations regarding timing of surgery vary. We used the Swedish hip fracture registry RIKSHÖFT and two administrative registries to explore the association between time to surgery and postoperative morbidity, as well as between time to surgery and time spent admitted to hospital, up to 120 days after the initial hospital discharge. Methods: 63998 patients ≥65 years old, admitted to a hospital between January 1^st, 2012 and August 31^st, 2017 were included. Primary outcomes were atrial fibrillation/flutter (AF), congestive heart failure (CHF), pneumonia and a combination of stroke/intracranial bleeding, myocardial infarction and acute kidney injury. Time to surgery was divided into <12 h, 12–24 h and >24 h. Crude and adjusted survival analyses were performed. Differences in time admitted to a hospital were tested using chi² tests. Results: For those waiting >24 hours, there was an increased risk of AF and CHF, and the risk of having CHF was slightly higher for women than for men. Overall, the patients who had waited 12–24 h had no increased risks compared with the patients operated <12 hours. Those waiting longer for surgery spent more time admitted to a hospital than those with shorter waiting times, but most patients of all groups had no readmissions. Conclusion: Waiting >24 hours for hip fracture surgery is associated with worse outcomes, which should be considered when creating new guidelines.

P017: The Feasibility and Benefits of Preoperative Whey Protein-Infused Carbohydrate Loading in Elderly With Hip Fractures Undergoing Surgery: A Pilot Study

K. S. Yap ^*1 , T. I. W. Ong ² , H. M. Khor ² , and P. S. Loh ¹

¹ Department of Anaesthesiology, University Malaya Medical Centre, ² Department of Medicine, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysi

Introduction: Preoperative carbohydrate loading in Enhanced Recovery After Surgery (ERAS) is an independent predictor of postoperative outcomes. By reducing the impact of surgical stress response, fasting-induced insulin resistance is modulated. As a clear fluid, consuming whey protein-infused carbohydrate is safe up to 2 hours preoperatively. Widely practiced in abdominal surgeries, its implementation in hip fracture surgeries is yet to be recognized. Methods: We aim to identify the feasibility of preoperative carbohydrate loading in hip fracture surgery and assess its clinical effects. A randomized controlled, open labelled trial in patients ≥ 65 years old without diabetes mellitus, has hip fracture was conducted in University Malaya Medical Centre between November 2020 and May 2021. Intervention: Carbohydrate loading (Resource-Nestle^®) with 100g on the day before surgery and 50g up to 2 hours preoperatively versus standard preoperative fasting. Results: Thirty ASA 1-3 patients (carbohydrate loading and control, n = 15 each), mean age 79 years (SD±8.5), mean body mass index 23.8 (SD±3.5kg/m²) were recruited. Analysis for feasibility of carbohydrate loading (n = 15) demonstrated attrition rate of 20%, n = 3 (one participant completed the drinks but operation was postponed and two patients were not served the third drink by ward staff). Otherwise, patients were 100% compliant with no adverse events reported. 26 randomized participants were analyzed for secondary outcomes (intervention n = 12, control n = 14). There was no significant difference among groups in the postoperative nausea and vomiting, pain score, fatigue level and muscle strength assessed at 24–48 hours postoperatively. Conclusion: COVID-19 pandemic had interrupted recruitment resulting in a small number of participants. Nevertheless, this study demonstrated that implementation of preoperative carbohydrate loading is feasible for hip fracture surgeries without complications but requires careful coordination among surgical, anaesthetic and nursing teams. An adequately powered randomized controlled study is needed to examine the full benefits of preoperative carbohydrate loading in this group of patients.

P018: Comparison of Two Different Types of Proximal Femoral Nails in the Treatment of Intertrochanteric Femur Fracture

A. S. Nazlıgül ^*1,2 , I. Duran ^3,4 , S. Akçaalan ^3,4 , C. Çağlar ⁴ , M. Asiltürk ⁴ , and M. Akkaya ³

¹ Orthopaedics, Ankara Yıldırım Beyazıt University, ² Orthopaedics, Ankara City Hospital, ³ Ankara Yıldırım Beyazıt University, ⁴ Ankara City Hospital, Ankara, Turkey

Introduction: Intramedullary nailing has become a popular method of stabilisation of proximal femoral fractures in adults. Due to the increasing age of the elderly population, the incidence of intertrochanteric hip fractures has been increasing. Proximal Femoral Nail Antirotation (PFNA) is a commonly used method to treat intertrochanteric hip fractures in elderly patients. In this study, we compared the postoperative hospital stay, mortality, radiological outcomes, and complication rates of patients treated with two different PFNAs. Methods: 56 patients who were operated for intertrochanteric femur fracture were included in this single center study. Patients were divided into two groups based on the proximal femoral nail antirotation used. Of these, 35 patients were treated with PFNA with interlocking, integrated two lag screws and 21 patients were treated with PFNA with single lag screw. There were no statistically significant differences between the groups in terms of age, sex and reduction quality measured on the first postoperative radiograph. The patients were followed up for 6 months postoperatively. Results: Mortality did not develop in any patient during the hospital stay. A total of 9 patients died before reaching sufficient follow-up time. There was no statistically significant difference between the groups in terms of postoperative hospital stay, mortality, complications, varus collapse, maintenance of reduction and fracture union. Conclusion: There was no significant difference in the treatment of trochanteric femoral fractures between PFNAs with interlocking, integrated lag screws and PFNAs single lag screw.

P019: What Are the Comparative Benefits and Risks of NSAIDS and Opioids in the Fragility Hip Fracture Population? A Scoping Review

J. Spiers ^*1 , and I. Moppett ¹

¹ University of Nottingham, Nottingham, UK

Introduction: Achieving adequate analgesia in the fragility hip fracture population can be difficult. The average age of a person with a hip fracture is 84 and more than 60% of patients in this population have at least one co-morbidity that could alter metabolism or excretion of drugs. Opioids are recommended for perioperative analgesia in the elderly hip fracture patient however they carry a significant side effect profile. Non-steroidal anti-inflammatory drugs (NSAIDs) are a potentially underutilised form of analgesia. The purpose of this scoping review was to provide an overview of the use of opioids versus NSAIDs in the elderly hip fracture population. Methods: Articles investigating adults aged 65 and over sustaining a hip fracture and opioid and/or NSAIDs as an analgesic intervention were included. Results: The search yielded 545 unique articles, of which 26 were included in the final synthesis. There were no studies directly compared opioids with NSAIDs in the elderly hip fracture population. We also found heterogeneity of outcome measures across studies and side effect profile reporting was scant. Conclusion: This scoping review demonstrates that there is a paucity of data regarding NSAID use in the elderly hip fracture population. Future randomised control trials comparing a short course of NSAIDs vs control analgesia would help to ascertain the risk/benefit and efficacy in this population. We have also identified that recent work regarding core outcome sets in this population has potentially helped to reduce heterogeneity between future studies to facilitate meta-analysis.

P020: The Influence of Mode of Anaesthesia on Perioperative Outcomes in People With Hip Fracture: A Prospective Cohort Study From the National Hip Fracture Database for England, Wales and Northern Ireland

G. Matharu ¹ , A. Shah ^*2 , S. Hawley ¹ , A. Johansen ³ , D. Inman ⁴ , I. Moppett ⁵ , M. Whitehouse ¹ , and A. Judge ¹

¹ University of Bristol, Bristol, ² Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, ³ University Hospital of Wales, Cardiff, ⁴ Northumbria Healthcare NHS Foundation Trust, Newcastle, ⁵ University of Nottingham, Nottingham, UK

Introduction: Delirium is common after hip fracture surgery, affecting 25% of patients, and may be influenced by anaesthesia. We examined the effect of spinal anaesthesia (with and without sedation) compared with general anaesthesia on early outcomes following hip fracture surgery, including delirium. Methods: We used prospective data on 107,028 patients (2018–2019) from the National Hip Fracture Database, which records all hip fractures in patients aged 60 years and over in England, Wales and Northern Ireland. Patients were grouped by anaesthesia: general (58,727; 55%), spinal without sedation (31,484; 29%), and spinal with sedation (16,817; 16%). Outcomes (delirium 4AT score day one postoperatively; mobilisation day one postoperatively; length of hospital stay; discharge destination; 30-day mortality) were compared between anaesthetic groups using multivariable logistic and linear regression models. Results: Compared with general anaesthesia, spinal anaesthesia without sedation (but not spinal with sedation) was associated with a significantly reduced risk of delirium (OR = 0.95, CI = 0.92–0.98), increased likelihood of day one mobilisation (OR = 1.06, CI = 1.02–1.10) and return to original residence (OR = 1.04, CI = 1.00–1.07). Spinal without sedation (P < 0.001) and with sedation (P = 0.001) were both associated with shorter hospital stays. No differences in mortality were observed between anaesthetic groups. Conclusion: Compared with general anaesthesia, spinal anaesthesia without sedation was associated with improved perioperative outcomes, including reduced risk of delirium, increased likelihood of mobilisation day one postoperatively, return to original residence, and shorter hospital stay. Most benefits were not observed in spinal anaesthesia with sedation, suggesting sedation may influence perioperative outcomes in hip fracture patients.

P021: The Effectiveness of a Co-Management Care Model on Older Hip Fracture Patients in China – A Multicentre Non-Randomised Controlled Study

J. Zhang ^*1 , M. Yang ² , X. Zhang ³ , J. He ⁴ , L. Wen ⁵ , X. Wang ⁶ , Z. Shi ⁷ , S. Hu ⁸ , F. Sun ⁵ , Z. Gong ⁷ , M. Sun ⁸ , Q. Li ⁹ , R. Ma ² , S. Zhu ² , X. Wu ² , R. Webster ^9,10 , R. Ivers ^1,9 , and M. Tian ^3,9

¹ School of Population Health, Faculty of Medicine, University of New South Wales, Sydeny, Australia, ² Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, ³ The George Institute for Global Health, Peking University Health Science Centre, ⁴ Department of Orthopaedics, Beijing Shunyi District Hospital, ⁵ Department of Orthopaedics, Beijing Hospital, ⁶ Department of Orthopaedics, Beijing Changping District Hospital, ⁷ Department of Orthopaedics, Beijing Liangxiang Hospital, ⁸ Department of Orthopaedics, Beijing Anzhen Hospital, Beijing, China, ⁹ The George Institute for Global Health, Faculty of Medicine, University of New South Wales ¹⁰ Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydeny, Australia

Introduction: Hip fracture (HF) is a severe injury among older people. Few studies have evaluated orthogeriatric care in China. We aimed to prospectively evaluate the effectiveness of co-management care in China on six standards recommended in the UK hip fracture best practice guideline. Methods: This non-randomised controlled study was conducted in 3 urban and 3 suburban hospitals from Nov 26^th, 2018, to Nov 25^th, 2020. Patients were followed-up three times (1, 4-month and 1-year post admission). Eligible patients were aged ≥ 65 (X-ray confirmed HF) and admitted to hospitals within 21 days of injury. The co-management care involving orthopaedics and geriatricians was implemented in 1 urban hospital. Other 5 hospitals were the usual care. Patient demographics, pre-, peri- and post-operative information, complications and mortality were collected. The primary outcome was the proportion of patients receiving surgery within 48 hours from ward arrival. Secondary outcomes were the other five standards of the UK guideline, length of hospital stay, hours from the ward arrival to surgery and hours from ED arrival to the ward. A log-binomial regression and multivariable linear regression model were used for binary and continuous outcomes, respectively. The exploratory outcome was one-year mortality. Kaplan-Meier cumulative event curves were generated. A cox proportional hazards regression model was used to test the difference between the two groups, calculating hazard ratio (HR). Confounders (p-value around 0.1) were identified from demographic and clinical data in single variable analysis and adjusted in regression models. Results: There were 2,071 eligible patients enrolled in the study (intervention, 1,110; control, 961). Compared to the usual care, significantly higher proportions were identified in co-management care (received surgery within 48 hours [75% vs 23%, P < 0.0001]; received osteoporosis assessment [99.9% vs 60.6%, P < 0.0001]; received geriatrician assessment [97.7% vs 0, P < 0.0001]; received rehabilitation [99.1% vs 3.9%, P < 0.0001]), while one-year mortality in the intervention group was significantly lower (HR 0.59, P = 0.01). Other outcomes were not significantly different (developed pressure ulcers [3.0% vs 1.8%, P = 0.15]; received falls assessment [98.9% vs 97.6%, P = 0.72]). Conclusion: Co-management care of older HF patients resulted in better outcomes, including prompt surgery, improved management and reduced one-year mortality. A randomised controlled trial would provide more robust evidence.

P023: Is Transdermal Buprenorphine Safe and Effective for Management of Pain in Patients With Hip Fracture?

A. Davies ¹ , J. Murray ¹ , P. Zalmay ^{* 2} , E. Ross ² , S. Dar ² , and H. Wilson ²

¹ Imperial College London, ² Royal Surrey Hospital NHS Trust, London, UK

Introduction: Managing pain in patients with hip fracture can be challenging. Poor pain control is associated with reduced mobility and increased morbidity, including pneumonia, delirium and pressure ulcers. There have been concerns about inadequate analgesia in patients with dementia. Having trialed several different alternatives, transdermal buprenorphine was chosen as a standardised approach for analgesia in patients with fragility fracture in our Trust. A BuTrans 5mcg/hour patch is administered weekly and is thought to be equivalent to 10–15 mg of oral morphine per day. There is limited evidence on the use of buprenorphine in these patients. Our aim was to investigate the safety and effectiveness of transdermal buprenorphine in patients with hip fracture. Methods: A review of consecutive patients presenting with hip fracture from June to December 2018 was conducted using medical records. Fascio-iliaca compartment block is offered in A&E to all eligible patients. Pre-printed drug charts suggest regular paracetamol and a BuTrans 5mcg/hr patch pre-operatively. Oral morphine liquid at a dose of 2.5–5 mg as required is recommended for breakthrough pain. Our primary outcome was the incidence of complications likely to be as a consequence of transdermal buprenorphine. Our secondary outcome was adequate analgesia measured by reviewing the requirement for breakthrough. Adequate analgesia was agreed if a patient required less than a total of 20mgs of oral morphine during the first week. Results: In total 148 patients presented with hip fracture during the study period. Complete data was available for 128 for the primary outcome and 118 for the secondary outcome. Buprenorphine was discontinued in 24 patients (19%) due to drowsiness, nausea or ineffective pain control. There were no severe complications. Adequate analgesia was achieved using this regime in 68% patients. 38 patients (32%) required more than 20mg oral morphine sulphate solution in the first week. Data from the National hip fracture database demonstrated outcomes including post-operative delirium and mortality for our trust being well below national average and day one mobilization being better than average. Conclusion: Transdermal Buprenorphine was chosen to ensure those with dementia received adequate analgesia and for ease of administration for nursing staff. This large case series demonstrates that transdermal buprenorphine appears to be effective and safe in patients with hip fracture.

P024: Mortality Following Fractured Neck of Femur in the Peri-Centenarian Population

C. Chan ^*1 , T. Stringfellow ¹ , P. Heard ¹ , and P. Buddhdev ¹

¹ Trauma & Orthopaedics, Broomfield Hospital, Mid & South Essex NHS Trust, Chelmsford, UK

Introduction: Orthopaedic trauma services are predicted to treat an increasing number of elderly patients. Those over 99 years sustaining Neck of Femur(NOF) fractures represent a uniquely complex patient group. The 2020 NHFD reported a 30-day mortality rate of 6.5%. We investigated the mortality and outcomes in the peri-centenarian population. Methods: A retrospective single-institutional study of NOF fracture patients ≥99 years old presenting from 2009 to 2020 was conducted using an electronic trauma database and NHFD. Data collection included patients’ demographics, diagnosis, functional and cognitive status(AMTS), length of stay(LOS) and mortality. Fisher’s exact test was used to analyse categorical variables. Results: A total of 67 patients with mean age 101 years (range: 99–107) presented during the study period; 57(85%) were female with an even distribution of intra- and extracapsular fractures. Mean follow-up time post-injury was 6.24 years (9 months to 11.5years). Male patients were more likely to sustain intracapsular fractures (80% vs 46%). Patients were largely admitted from their own home (39, 58%), with 88% (n = 59) having surgery within 36-hours. Mean LOS was 14.4days, shorter than NHFD reported 19.3days. 11 deceased during primary admission; only 3 of the remaining 56 patients required escalation of care post-discharge. Overall crude mortality rate was 78% (median time 89 days); extracapsular fractures had increased mortality (91% vs. 62%, P = 0.0087). Cumulative mortality rate was 21%, 39%, 46% and 49% at 30days, 3, 6 and 12 months, respectively. There was no statistical correlation between residential status, mobility levels, AMTS scores, ASA-grade or LOS and mortality rate. Conclusion: 89% of peri-centenarian patients returned to their pre-admission residential institutions with over half surviving 1-year. The 30-day mortality rate was 21% with a predominance in extracapsular fractur patients. It is important not to assume patients over 99 years do poorly after NOF fractures and timely treatment should be prioritised in this patient group.

P025: Chronic Opioid Use After Elderly Hip Fracture Repair

T. Hereford ^*1 , S. Mears ² , and A. Porter ²

¹ Orthopedic Surgery, ² UAMS, Little Rock, USA

Introduction: While interest has focused on opioid use after hip replacement, little research has investigated opioid use in elderly patients after hip fracture. We hypothesize that a substantial number of opioid-naïve elderly patients will go on to chronic opioid use after surgery for a hip fracture. Methods: 219 patients 65 years and older that underwent surgical fixation between 1/1/16 and 2/28/19 for a native hip fracture were reviewed (mean age 81 years old; 150 female, 69 male; mean BMI 24.5). Patients were excluded for polytrauma, periprosthetic fractures, pathologic fractures, or if they died or had other major surgery within 90 days of their hip surgery. The state prescription monitoring database was used to determine opioid use. Patients were considered opioid naïve if they did not fill a prescription in the three months before surgery. Chronic opioid use was defined as filling a prescription 6 months after surgery. Results: Overall, 58 patients (26%) were chronic opioid users. Of the 188 opioid naïve patients, 43 (23%) became chronic users. Of the 31 non-opioid naïve patients, 15 (48%) were chronic users. Chronic users were more likely to be male (34 of 58, 59% versus 43 of 158, 27%, P = 0.05), had a lower age (78 versus 82 years old, P = 0.003), and were more likely to be white (53 of 58, 91% versus 125 of 158, 76%, P = 0.04). Fracture type, surgery type, and discharge destination did not affect the rate of chronic use. Arthroplasty (hemi, total) versus non-arthroplasty (cannulated screws, DHS, IMN) surgical options did not affect rate of chronic use. Conclusion: A significant portion of elderly patients with a hip fracture will become chronic opioid users after surgery. Surprisingly, 23% of patients who were opioid naïve before surgery became chronic users. Being younger, white, and male were risk factors for chronic usage. Continued vigilance is needed by orthopedic surgeons to avoid chronic narcotic usage after hip fracture repair.

P026: Perioperative Management and Outcomes of Hip Fracture Patients With Advanced Chronic Kidney Disease

C. Ongzalima ^*1 , K. Dasborough ¹ , S. Narula ¹ , G. Boardman ¹ , P. Kumarasinghe ¹ , and H. Seymour ¹

¹ Fiona Stanley Hospital, Murdoch, Australia

Introduction: Hip fracture (HF) is a significant risk to Australia’s ageing population. Patients with advanced chronic kidney disease (aCKD) are at risk of fragility fracture secondary to impaired bone and mineral metabolism. Our research aims to explore clinical characteristics, perioperative management and outcomes of Hip Fracture patients with advanced Chronic Kidney Disease (HF-aCKD) compared to the general Hip Fracture population without aCKD (HF-G) within a large volume tertiary hospital in Western Australia. Methods: Retrospective chart review of patients admitted with fragility hip fracture (HF) to a single large volume tertiary hospital who were registered on Australian and New Zealand Hip Fracture Registry (ANZHFR). We compared baseline demographic variables and clinical frailty scale in HF-aCKD (n = 74) defined as CKD with eGFR <30mls/min and HF-G (n = 452) and determined their outcomes at 120 days. Results: We identified 74 (6.97%) hip fracture patients with aCKD. General demographics were similar in HF-aCKD and HF-G populations. Proportionally there were more aCKD patients that were “frail” (CFS 5-6), than “severely frail” (CFS ≥ 7) or “vulnerable” (CFS 4). 120-day mortality for HF-aCKD was double that of HF-G population (34% vs 17%, P = 0.001). For dialysis patients, 120-day mortality was triple that of HF-G population (57%). Except for the fit category of HF-aCKD group, higher CFS was associated with higher 120-day mortality in both groups. Of all HF-aCKD, 96% patients had operative intervention, 48% received blood transfusion, 51.8% returned home after admission for HF. There were no new starts to dialysis peri-operatively. Each point reduction in eGFR below 12mL/min/1.73 m2 was associated with 3% increased probability of death in hospital. Conclusion: 120-day mortality was double in HF-aCKD and triple in HF-dialysis that of the HF-G within our institution. CFS can be useful in predicting mortality after HF in frail aCKD patients. High rate of blood transfusions was observed in HF-aCKD group.

P027: A Completed Audit Cycle Examining Quality Improvement Pre and Post Introduction of Ed Multi-Disciplinary Simulation Based Medical Education Training on the Tallaght Hospital Hip Fracture Pathway

C. Clancy ^*1 , R. Mahony ¹ , and V. Meighan ¹

¹ Tallaght University Hospital, HSE, Dublin 8, Ireland

Introduction: The care of patients with hip fractures is a surrogate marker of trauma care. Irish hip Fracture Standard 1 involves patients with a hip fracture being admitted to an orthopaedic ward bed within 4 hours of attending the ED. We wanted to audit our current practice and introduce a quality improvement project to improve the timeliness and efficiency of care of our hip fracture patients compared with the gold standard IHFS 1. We introduced a 90-minute multidisciplinary simulation training programme on the hip fracture pathway to our ED in February 2021. All key stakeholders were represented; from Emergency Medicine, Orthopaedics, Nursing (EM and Orthopaedic), Radiology, Radiography, Porters (32 people overall). Because of Covid-19, the training was available in person and online via zoom. Methods: We performed a retrospective audit of patients presenting to TUH ED with a proximal third of femur fracture between 4^th February and 31^st March inclusive in 2020 and 2021, pre and post introduction of multidisciplinary simulation based medical education on the hip fracture pathway. Data was collected from the electronic record database (symphony). Results: 2020 n = 31; Average time to ward – 8hrs 29 mins. 26% patients reached ward <4 hours. (8/31). 2021 n = 25; Average time to ward – 5hrs 58 mins (32% reduction vs 2020). 72% patients reached ward <4 hours. (18/25) (46% increase vs 2020). Conclusion: Simulation based medical education is a successful intervention to improve compliance with our hip fracture pathway, time from presentation to transfer to an orthopaedic ward bed and achieve IHFS 1.

P028: A Finite Element Analysis of Fracture Obliquity on the Stability of Tension Band Wiring in the Treatment of Olecranon Fractures

J. Ng ^*1 , S. Z. R. Poh ² , B. Y. Tan ³ , Y. K. J. Liong ² , and E. B. K. Kwek ³

¹ National Healthcare Group, ² Singapore Institute of Technology, ³ Orthopaedic Surgery, Woodlands Health, Singapore, Singapore

Introduction: Tension band wiring (TBW) is a common form of fixation for olecranon fractures which occur commonly in the elderly. More unstable, oblique fractures are thought to not do as well and the more expensive plate fixation is preferred. This study aims to elucidate the limits for which simple olecranon fractures can be safely fixed using a tension band wire construct. Methods: An anonymised, CT scan of the right upper limb of a middle aged male was used to create a 3D model of the ulna using MIMICS (v19.0, Materialise, Belgium). This was subsequently exported to SOLIDWORKS (Dassault Systèmes, France) for modelling of the TBW construct and creation of fracture lines at the midpoint of the olecranon at 90, 75, 60 and 45 degrees to the long axis of the ulna. Finite element analysis was carried out using ABAQUS. The model was constrained proximally, and increasing axial loads of 50N, 250N and 500N was applied distally. Displacement was measured in the X, Y and Z axis for nodes placed along the fracture line. Results: A total of 36 analysis was carried out with ABAQUS. At axial loads of 50, 250 and 500N, the tension band wire construct demonstrated good stability with minimal displacement in all axis at all fracture angles. There was a trend towards increased fracture displacement with greater loads. There was an increase in fracture displacement associated with decreasing fracture angle, most markedly at fracture angle below 60 degrees. At 500N of axial loading, net displacement was 0.000000183mm for the 90° fracture, 0.0043mm for 75° fracture, 0.0096mm for 60° fracture and 0.0132mm for 45° fracture. Conclusion: The tension band wire appears to be stable at loads up to 500N at fracture angles ranging from 45 to 90 degrees to the ulna shaft. It may be prudent to avoid early loading of more oblique fractures to prevent risk of displacement.

P029: Increasing Trend of Positive S-Ethanol in Elderly Hip Fracture Patients

M. I. Martinsen ^*1 , and A. Hylen Ranhof ²

¹ Clinic for anesthesiology and surgery, ² Medical department, Diakonhjemmet hospital, Oslo, Norway

Introduction: Drinking habits and alcohol consumption among older people in Norway is changing. Consumption of more than 14 units alcohol per week is known to increase risk for hip fractures, probably contributing to both osteoporosis and fall risk. Serum-alcohol on admission in patients with hip fractures is poorly studied. Our quality registry of older hip fracture patients includes data on s-ethanol on admission from 2015 and from 2017 and onward. The aim of this study was to see whether the number of patients with positive s-ethanol was increasing compared to 2015, and to study patient characteristics. Methods: A cross-sectional prospective observational study in the aim to improve clinical practice, with data from a quality registry. Demographic and medical information were collected by an interdisciplinary team. Results: In 2015, 17 of 427 hip fracture patients (4%) had positive s-ethanol with range 0.4–2.9 mg/l. From 1.1.2017 to 31.12.2020, 1239 home-dwelling patients aged ≥ 65 year, 833 (72%) women, were included and 89 (7 %) had positive s-ethanol on admission, 59 (67%) were women. Number of patients with positive s-ethanol were almost the same in 2017 and 2018, 17 (5%) and 18 (5%) as in 2015. In 2019 and 2020 the number of patients with positive s-ethanol were 27(9%) and 25 (11%). Mean age was lower in patients with positive s-ethanol (77 (range 65–97vs 83 (range 65–103) years. In 2015 none of the patients with positive s-ethanol were 90 years or older, in 2017–2020 7 (8%) were ≥ 90 years. Patients with positive s-ethanol had less chronic diseases than those without; mean score on Charlsons’ index 0.9 vs 1.2. 18 (20%) of the patients with positive s-ethanol had delirium vs 370 (32%) in patients without. Range s-ethanol was 0.1–3.5 mg/l. 39 (44%) of the patients had s-ethanol ≤ 0.5mg/l, 22 (25%) 0.6–1.0, 20 (22%) 1.1–2.0 and 12 (13%) had s-ethanol >2.0 mg/L. In 2015 5 (31%) of the patients had ≤ 05 mg/l s-ethanol. Conclusion: Routine analyses of s-ethanol in older hip fracture patients detected few patients with positive s-ethanol. However, we found an increasing trend in number of patients with positive s-ethanol. These are small numbers, and s-ethanol in elderly hip fracture patients needs to be further studied.

P030: The Burden of Medical Consults in the Absence of an Orthogeriatric Service

N. Davey ^*1 , B. Conlon ¹ , P. Monahan ¹ , and H. O'Brien ¹

¹ OLOL Drogheda, Co Dublin, Ireland

Introduction: The initial collaboration between geriatric medicine and orthopaedics has evolved into a subspecialty of orthogeriatrics as a response to the complex medical, rehabilitation, and social needs of this patient group. The aim was to examine the impact on medical teams in the absence of an orthogeriatric service over a one week period. Methods: We retrospectively reviewed the charts of orthopaedic inpatients over a two week period; the first week occurred in the presence of daily orthogeriatric review and the second week occurred in the absence of this subspecialty service. Results: 20 individual patients were included over this two week period; six of these patients were admitted in the latter week. We included in hours and out of hours review. The patients included in the second week all fit the criteria for orthogeriatric review (age > 65y/o, sustained an osteoporotic hip fracture) and would have been reviewed by the orthogeriatric service soon after admission if there was an orthogeriatric service in situ. Three patients were not included as their charts were not located. In the first week, the mean patient age was 80.29 years; 78.6% were female and no deaths occurred. There were a total of three medical reviews to the Haematology, Endocrinology and Palliative care teams, respectively. In the second week , the mean age was 85.44 years, 62.5% were female and there was a single death. There were a total of seven medical reviews to Haematology, Medicine for the Elderly and two, respectively, to Palliative Care and the on call Medical team. Conclusion: Our findings demonstrate the need for a dedicated orthogeriatric service to provide a comprehensive geriatric assessment. The Orthogeriatric service reduces the number of medical consults, improves continuity of care and ensures patient-centred rehabilitation goals. Preserved Orthogeriatric services are essential at all times.

P031: Service Mapping Process of Orthogeriatric Service in University Malaya Medical Centre (UMMC) Malaysia

H. T. Lim ^*1 , T. I. W. Ong ¹ , H. M. Khor ¹ , C. S. K. Chandrasekaran ² , S. S. Jagdis Singh ² , Y. K. Adnan ² , and M. R. Draman@Yusof ²

¹ Department of Geriatric Medicine, ² Department of Orthopaedic Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia

Introduction: Fragility hip fractures among older people lead to significant morbidity and mortality. Previous study showed median time from admission to surgical intervention was 5 days. We aim to identify factors associated with the delay. Methods: We analyzed medical records of all patients under orthogeriatric care who had hip surgery, admitted between 1.8.2020 and 31.10.2020. Results: A total of 42 patients with mean age of 77.8 years were recruited. 32 (74.4%) patients had surgery performed >48hours post-admission with median waiting time of 4 days (interquartile range = 3). Patients with delayed surgery had significantly more medical issues (X ² (1, N = 42) = 4.01, P = 0. 045). 13/42 (42.9%) of patients had one medical condition while 12 cases had more than one preoperatively. Medical conditions commonly encountered were infection (5/42, 11.9%), electrolyte imbalances (11.9%) and acute kidney injury (4/42, 9.5%). Cardiology referral (18/42) was the most frequently made prior to the operation. However, only cardiac risk profiling was provided for 14 cases. 6 out of 18 referrals (33.3%) had input from cardiology registrar/ consultant. 19 cases (45.2%) were planned for echocardiogram prior to hip surgery and no significant change in management was noted following echocardiogram. Other reasons for delay in surgery include anaemia requiring blood transfusion (2/42; 4.8%), use of anticoagulants (2.4%), lack of ICU beds (2.4%), financial constraint/delay in obtaining consent from next of kin (11.9%). Conclusion: We identified cardiology referral, pre-operative medical optimization and the wait for echocardiogram are key areas that can be improved. These delays can be resolved by re-organising referral pathways and multidisciplinary engagement.

P032: First Impressions of the Impact of a Nurse Practitioner on an Understaffed Orthogeriatric Service

S. Sweeting ^*1 , and T. Fleming ²

¹ Trauma and Orthopaedics, ² Somerset NHS Foundation Trust, Taunton, UK

Introduction: A recent British Orthopaedic Association article highlighted the workforce challenges associated with orthogeriatrics and recommended the use of alternative workforce, such as clinical nurse practitioners (CNP). The recent fragility fracture network call to action also highlighted 4 pillars of fragility fracture care for which expert nursing is key. As our local orthogeriatrics service has expanded we have been unable to recruit sufficient doctors. Therefore in December 2020 we decided to redeploy an orthopaedic CNP into orthogeriatrics. The CNP is responsible for numerous roles including completion of discharge summaries. The aim of our study was to assess the impact that the addition of an orthogeriatrics CNP had on our communication of osteoporosis treatment with patients and primary care. Methods: We conducted a retrospective review of discharge summaries for patients who had a hip fracture during the periods of May 2020 and May 2021, i.e. six months pre and post employment. The review assessed if there was evidence of communication regarding osteoporosis treatments on the summaries. We also checked if the summaries were electronically sent to the fracture liaison service for follow up. Consultant designed snippets have always been available to explain treatment plans in detail, therefore the use of these versus free text instructions by the author were also evaluated. Results: 42 patients had a hip fracture during May 2020, and 47 patients during May 2021. 83% (39/47) of May 2021 summaries had treatment advice compared with 71% (30/42) in May 2020. 21% (10/47) of summaries from May 2021 were sent to the fracture liaison service compared with 9% (4/42) in May 2020. There was also a marked improvement in the quality of information provided for primary care in May 2021. Conclusion: The introduction of a CNP has had a positive impact on communication with patients, fracture liaison service and primary care. This will translate into better drug adherence & monitoring, and reduced fracture rate in the long term. Our local service has also noted multiple other benefits of orthogeriatrics CNP such as improved working relationships with other health professionals and greater efficiency on ward rounds. This has resulted in higher quality patient care and timely ordering of investigations, aiming to prevent delays to discharge.

P033: Hip Fractures – Lets Talk About Men: A Prospective Study on Outcomes Post Hip Fractures

R. Sullivan ^*1 , C. Small ¹ , S. Khan ¹ , S. o'Hanlon ¹ , M. T. Cooney ¹ , and R. Doyle ¹

¹ Medicine for Older Persons, St Vincents University Hospital, Dublin, Ireland

Introduction: Hip fractures are a common presentation in the older population, having a significant impact on morbidity and mortality. Studies have looked at pre-fracture function to help predict outcomes in this heterogeneous group. Frailty tools are useful to highlight high-risk groups and tailor post op management. Independent of frailty, gender is another factor that may predict post op recovery. The aim of this study was to analyze gender differences in mortality and functional outcomes post operatively. Methods: This prospective observational study of patients over 60 years admitted with a neck of femur (NOF) fracture to a tertiary hospital between February 2016 and July 2018. Data was collected on baseline demographics as well as type of surgery and discharge destination. During their orthogeriatric assessment, three functional scores; Clinical Frailty Scale (CFS), New Mobility Scale (NMS) and the Zuckermann functional recovery score (FRS) were calculated and repeated at the follow up telephone clinic at one year. Results: 634 patients were admitted with NOF over the age of 60. 541 had complete data. The average age was 82 years. The average length of stay was 18 days. The incidence of dementia was 31% and delirium was identified in 33.5% of men and 28.3% of women. The mortality rate at one year for men was 32% compared to 21% for females (OR: 1.75 P = 0.005). After adjusting for age, frailty scores and nursing homes admissions, the difference in mortality remained significant (OR 1.99 (CFS), OR 1.86 (FRS), OR:1.9 (NMS) P < 0.005). The mortality risk in men was the equivalent of being 15 years older in women (OR 1.89 P = 0.03). Men were twice as likely to be in a nursing home or dead at one year adjusting for age and frailty (OR 2.06 P = 0.01) and five times more likely if the CFS is ≥6 (OR 5.5 P < 0.05). On admission, 48% of Men and 41.7% of women were non-frail (CFS1-4). 30% of men and 33.4% of women were classified as moderately frail (CFS 5-6) and 12.5% of men and 16.8% of women were deemed severely frail (CFS 7-8). At one year, 44% had no change in their frailty level (31% men and 50% women, p for diff 0.001). Men were more frail at one year.(56% men and 43% of women, p for diff 0.0292). Conclusion: Gender is an independent predictor of mortality and nursing home admissions post hip fractures that cannot be explained by age or level of frailty. Are these differences due to the variable prevalence of morbidity between men and women? Further studies are needed to explore these differences.

P034: Can a Brief Teaching Video Enhance Staff Confidence and Improve Pain Management in Hip Fracture Patients? A Preliminary Study

H. Garside ^*1 , and A. MacLullich ^2,3

¹ University of Edinburgh, ² Usher Institute, University of Edinburgh, ³ Chair, Scottish Hip Fracture Audit, Edinburgh, UK

Introduction: High levels of pain in acute hip fracture patients are associated with multiple adverse outcomes. Studies show that pain management in hip fracture patients is often inadequate. This preliminary study aimed to evaluate staff confidence on pain assessment in hip fracture patients, to assess responses to a new brief (2 minute) educational video, and to seek preliminary evidence of whether the video could improve pain management. Methods: We designed a survey for nurses and junior doctors of confidence in management of pain in hip fracture patients and using the hospital hip fracture pain protocol. We measured pain in acute hip fracture patients using a 10-point scale. We produced a video (www.the4AT/hip) highlighting key points including assessment in cognitively impaired patients. Two different groups of 20 staff completed the survey, one before and one after viewing the video. The pain assessments were performed in two different groups of 20 patients before and after (around 2 weeks) dissemination of the video. Results: Compared to before the video, staff after the video reported higher confidence in understanding the pain protocol and assessing pain in cognitively impaired patients. There was no difference in confidence in assessing pain in cognitively intact or drowsy patients. All staff in the after video group agreed that the video was useful and informative. Considering pain management and measurement, the after video group of patients were prescribed higher doses of oxycodone regularly and ‘as required’. More patients after the video were prescribed alfentanil ‘as required’. Additionally, patients received more ‘as required’ doses of pain relief in after video group. Notably, patients who were cognitively intact received more ‘as required’ doses than those who were cognitively impaired. Pain levels were lower, on average, in the after video group and patients with higher pain levels received more ‘as required’ medication. Conclusion: In this preliminary study we found that a brief educational video was well-received and may have been associated with higher staff confidence in assessing and managing pain. Patients received more analgesia and had lower pain levels in the after video group. These preliminary results provide supportive evidence for the value of a brief and simple educational video in improving pain management in hip fracture patients. Further work is needed to improve knowledge and attitudes particularly in relation to cognitively impaired and drowsy patients.

P035: Multidisciplinary Management of an Outbreak of COVID-19 on an Orthopaedic Rehabilitation Ward: A Description of Outcomes

C. Henry ^*1 , S. Murphy ¹ , E. Stanley ² , and E. Aherne ²

¹ orthogeriatric medicine, South Infirmary Victoria University Hospital, ² Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland

Introduction: In January 2021, Ireland was undergoing the ‘Third Wave’ of COVID-19, with almost 2,000 persons hospitalised with COVID-19. Over 50% of all COVID-19-related deaths in the EU have occurred in those aged 80 years and older. The same patient cohort is also at high risk sustaining a fragility fracture, leading to an admission to the orthopaedic rehabilitation ward. This study examines a patient group in whom these two scenarios coincided, describing a patient cohort who having sustained a fragility fracture, later contracted COVID-19. This study aims to describe the characteristics and outcomes of orthopaedic rehabilitation patients with COVID-19 and to examine the response of an orthopaedic rehabilitation ward to an outbreak of COVID-19. Methods: This is a retrospective observational study. Data from 26 hospitalised patients aged over 65 years with COVID-19 at an Irish orthopaedic rehabilitation ward was collected. Symptom profile, degree of COVID-19 severity, Clinical Frailty Scale (CFS), Charleston co-morbidity scores, laboratory and radiological data were reviewed. Individual treatment pathways were recorded for each patient. Infection control records were reviewed to examine the response of the ward to an outbreak of COVID-19. Results: Patient mortality rate was 7.7% (n = 2). Median survivor age was 79.5 years (IQR 70–85.5). Mean CFS and Charleston Co-morbidity scores were 4.15; (SD1.6) and 5.08, respectively. The majority of patients (n = 25, 96%) were categorised as mild COVID-19 cases. Delirium was noted in more than 10% of patients (n = 3, 11.6%). One patient (n = 1, 3.8%) required non-invasive ventilation. In those whose disease was classifies as severe (n = 2, 7.7%), intubation/resuscitation were not deemed appropriate and when they deteriorated, comfort measures were taken. The majority of patients (n = 21, 81%) were able to return home upon discharge. Three patients (11.5%) had increased care needs and required long term care to be arranged. Conclusion: An outbreak of COVID-19 requires a multidisciplinary approach with a focus on not only medical management but also clinical workforce management, patient flow, management of access to the wards and information and communications management. The overall outcomes in this group, including mortality and proportion discharged to long term care, were positive when compared to similar cohorts of elderly hospitalised patients with COVID-19. These outcomes support a multidisciplinary model of care.

P036: Impact of the COVID-19 Pandemic on Inpatient Falls

S. Kiyu ^*1 , H. Halim ² , M. Pelitini ³ , and E. Chong ¹

¹ Geriatric Department, ² Pharmacy Department, Hospital Kuala Lumpur, Kuala Lumpur, ³ Health department, Jabatan Keshihatan Negeri Sarawak, KUCHING, Malaysia

Introduction: Inpatient falls are common and can lead to injuries and prolonged hospitalisation. The Covid-19 pandemic has affected the operations in the hospital with a deficiency in nursing care and new ward protocols. The aim of this study is to assess the impact of the Covid-19 pandemic on inpatient falls and to identify the circumstances relating to the falls. Methods: This retrospective exploratory study was conducted in a 2,300-bedded urban public hospital in Kuala Lumpur. The data of falls incidences was obtained from the standardised hospital fall reporting system. The analysis compares the falls occurring from January to December 2019 prior to the Covid-19 pandemic and falls during the Covid-19 pandemic in January to December 2020. Results: There was a slight increase in the absolute number of patients who had a fall in the Covid-19 wards from March to December 2020 compared to the same wards (functioned as medical wards) prior to the Covid-19 pandemic from March to December 2019 (198 versus 235, respectively). The peak number of falls occurred in the 61 to 70 years old age group for the year 2020 (30.3%) whereas for the year 2019, majority of the falls occurred in patients aged above 70 years old (31.5%). Approximately 60% of the patients who had a fall were males during both periods. More falls occurred at the bedside (60%) for both years. During both periods, the majority of the falls occurred during the nurses’ night shift from 9:00 PM to 7:00 AM (43.6% in 2020 and 44.8% in 2019), during which the nurse to patient ratio is the lowest. In 2020, the top 3 causes of falls were loss of balance (26.5%), getting out of bed (17.5%) and wet floor(10.7%). In 2019, fall from bed (22.1%) was the most common cause, followed by wet floor (20.8%) and loss of balance (11.4%). During both periods, most of the falls did not cause any injury. Conclusion: Falls during the Covid-19 pandemic were mostly caused by loss of balance and getting out of bed, probably relating to the acute weakness due to the Covid-19 illness.

P038: A National Survey of Peri-Operative Blood Management for Hip Fracture Patients in Scotland

L. Farrow ^{*1, 2} , K. Ward ³ , J. McDonald ³ , K. Adam ³ , A. Duckworth ^{4, 5} , and C. Scott ⁴

¹ Institute of Applied Health Sciences, University of Aberdeen, ² Trauma and Orthopaedics, NHS Grampian, Aberdeen, ³ Public Health Scotland, ⁴ Edinburgh Orthopaedics, Royal Infirmary Edinburgh, ⁵ Usher Institute, University of Edinburgh, Edinburgh, UK

Introduction: The management of blood loss and anaemia is an increasingly recognised keystone in the peri-operative care of hip fracture patients. There is however much debate regarding the optimum management of anaemia and use of adjunctive treatments to reduce peri-operative blood loss. Understanding national variation in current treatment is an important first step towards optimising the care of peri-operative blood management for hip fracture patients. Methods: Through the Scottish Hip Fracture Audit (SHFA), an electronic survey was distributed to clinical leads of all 18 Scottish hospitals involved in the acute care of hip fracture patients during February 2021. Questions related to peri-operative blood loss and anaemia management, as well as research involvement. Results: 12/18 (67%) centres responded. 10/12 (83%) centres used the Scottish Consensus Statement for Management of Anticoagulant and Antiplatelet in Patients with Hip Fracture, with the other 2/12 (17%) centres using local guidelines alone. 10/12 (83%) centres routinely used Tranexamic acid (TXA) intra-operatively, with 3/10 (30%) centres providing it to all patients regardless of thromboembolism history. 1/10 centres gave a dose of TXA post-operatively. Cell salvage was routinely available in 1/12 (8%) centres. 4/12 (33%) centres used non-blood products regularly to manage anaemia. Only 2/12 (17%) and 4/12 (33%) centres had protocols in place for pre & post-operative anaemia, respectively. 7/10 (70%) hospitals currently employed what they categorised as a “restrictive” transfusion policy, whereas 3/10 (30%) utilised a “liberal” transfusion policy. All respondents considered reducing transfusion rates to be an important healthcare outcome. 9/10 (90%) would be willing to aid recruitment to future clinical trials investigating peri-operative blood management. Conclusion: We provide evidence of significant current variation in peri-operative blood management for hip fracture patients in responding hospitals across Scotland. Despite this there is widespread awareness of the importance of minimising blood loss and managing anaemia to improve the care of hip fracture patients. Respondents showed a clear willingness to contribute to future clinical trials within this area.

P039: The Management of Peri-Prosthetic Femoral Fractures: A Review of the First Year of Data Collection From the National Hip Fracture Database

J. Evans ^{* 1,2} , D. Inman ^2,3 , and A. Johansen ^2,4

¹ Musculoskeletal Research Unit, University of Bristol, Bristol, ² National Hip Fracture Database, Royal College of Physicians, London, ³ Northumbria Specialist Emergency Care Hospital, Northumbria Healthcare NHS Foundation Trust, Cramlington, ⁴ Trauma Unit, University Hospital of Wales, Cardiff, UK

Introduction: The National Hip Fracture Database (NHFD) started collecting data on peri-prosthetic femoral fractures (PPFF) in December 2019. This includes fractures around all implants (nails, plates, sliding hip screws, hemiarthroplasties and not just total hip and knee arthroplasties. To date, the main source of information on peri-prosthetic fractures has been the National Joint Registry, which only collects data on those treated with revision and not those treated conservatively or with open reduction and internal fixation (ORIF). Methods: We performed a retrospective review of PPFF reported to NHFD between 1 January and 31 December 2020. Individual patient level data were not available, and analyses consisted of a summary statistics review using the Crown informatics, pivot table tool used to generate the NHFD annual report. Results: In total, 2,616 PPFF were reported in 2020, of which 2,606 had complete data on location of fracture. Of the 2,405 fractures around hip or knee replacements with complete data on management, there were 1,695 fractures around a hip replacement (1,052 (62%) of which were Vancouver B), 577 around a knee replacement and 133 inter-prosthetic fractures. 1,970 fractures were known to be treated with surgery and 435 known to be treated conservatively. 135 hospitals reported a PPFF around a hip or knee replacement with a mean of 17.8 fractures per hospital (range 1, 110, IQR 8, 25) Overall, 26.3% of reported PPFF fractures with complete data were treated with revision surgery. Conclusion: We report that just over a quarter of PPFF reported to the NHFD in 2020 were treated with revision surgery. The NHFD data on PPFF are new and reporting may not yet be complete, and this is a limitation of this work. It does however provide the first snapshot of the number of PPFF being admitted to hospitals in England and Wales and the management strategies used. Periprosthetic femoral fractures are a potentially life changing injury in a vulnerable patient group and thought to be associated with increased morbidity and mortality. In our analysis of the NHFD from 2020 we have seen that only 26% of fractures around hip or knee replacements would have been reported to the NJR suggesting that research using the NJR dataset may not be generalisable. Future research needs to focus on better understanding this injury, in particular the epidemiology and outcomes before we can move forward with strategies for improving patient outcomes.

P040: Early Outcomes of Elderly Hip Fracture Management During the COVID-19 Pandemic: A Report From the Philippines

I. A. Tabu ^{* 1,2} , B. Alpuerto II ² , K. T. Araneta ² , G. Delgado ² , J. G. Lai ^{2 3} , J. A. San Juan ⁴ , M. R. Reyes ⁵ , J. De Vera ⁶ , J. F. Syquia ⁶ , R. E. Manalastas ⁷ , A. J. Tablante ⁸ , A. Brabante ⁹ , C. Dimayuga ^2,10 , J. Lin ¹⁰ , A. Ho ⁴ , D. Pacheco ¹¹ , P. Baclig ¹² , J. A. Yap ¹³ , A. S. Co ¹² , M. Soriaso ¹³ , and T. J. Arellano ⁷

¹ Department of Orthopedics, ² University of the Philippines Manila- Philippine General Hospital, ³ Cardinal Santos and Medical Center, Manila, ⁴ Chong Hua Hospital, Cebu, ⁵ Davao Doctors Hospital, Davao, ⁶ De Los Santos Medical Center, Manila, ⁷ Jose B. Lingad Memorial General Hospital, Pampanga, ⁸ Jose Reyes Memorial and Medical Center, ⁹ Philippine Orthopedic Center ¹⁰ The Medical City, Ortigas ¹¹ Veterans Memorial Medical Center, Manila ¹² Vicente Sotto Memorial Medical Center, Cebu ¹³ West Visayas State Univeristy Medical Center, Ilo-ilo, Philippines

Introduction: The multidisciplinary model of management for fragility hip fractures has only been recently introduced in the Philippines. Its development at the national and local level is made more difficult by the COVID-19 pandemic. To our knowledge, this is the first study to provide a comprehensive report on the clinical characteristics, current management and early outcomes of fragility hip fracture patients admitted during the COVID-19 pandemic in the setting of a country with an emerging economy. Methods: A multicenter prospective cohort study was conducted in the Philippines involving 12 hospitals from June 16, 2020 to February 28, 2021 during the Extended Community Quarantine Period during the COVID-19 pandemic. The clinico-demographic characteristics, treatments, and follow-up data at 30 days post-injury were gathered using the Research Electronic Data Capture (REDCAP) database system, using a minimum common data (MCD) which was adopted from the FFN MCD. Results: A total of 158 elderly patients (>60 years old) with fragility hip fractures were eligible for the study. 9 patients (5.7%) were confirmed or suspected to have COVID-19 infection. The median time of injury-to-admission was at least 3 (IQR: 1.0–13.7) days. 80% of the patients underwent surgical intervention with a median time from admission-to-surgery of at least 5 (IQR: 2.5–13.6) days. Notably, all non-COVID admitted patients had not been reported to have contracted the virus during their hospital stay. The 30-day mortality and morbidity rate for acute fragility fractures were 3.7%. Only the presence of a COVID-19 infection was found to be an independent and poor predictor for early mortality (P = 0.010). Conservatively managed patients had a significantly higher morbidity rate than surgically treated patients (13.6% vs 1.8%; P = 0.031). All five deaths occurred in non-surgical patients with an ASA grade of at least III. Conclusion: We recommend prompt admission and multidisciplinary care for elderly hip fracture patients even during the COVID-19 pandemic. Short-term outcomes remain favorable for non-COVID patients with acute fragility fractures treated with surgery. While a suspected or confirmed COVID-19 infection was the only significant and independent pre-operative risk factor for early mortality, there is evidence in the literature as well as in this study that the benefit of surgery may well outweigh the risk of conservatively treating COVID-19 patients provided that they can be optimized appropriately for surgery. 

P041: Utility of the Deltoid Tuberosity Index in the Proximal Humeral Fractures in the Asian Population

W. X. Ng ^*1 , B. Tan ¹ , and A. Sanchalika ²

¹ Orthopaedic Surgery, ² Clinical Research & Innovation Office, TAN TOCK SENG HOSPITAL, SINGAPORE, Singapore

Introduction: The proximal humeral fracture (PHF) is a fragility fracture with an exponential increase of prevalence over the age of fifty years. While most patients with sustained PHF can be treated non-operatively, displaced fractures that are treated surgically may have very poor local bone mineral density (BMD). This in turn makes fixation of PHF challenging and increases failure rates. Patients with poor local BMD may require surgical adjuncts such as strut allograft or the use of intramedullary nailing or even arthroplasty. The radiographically measured deltoid tuberosity index (DTI) is a tool described by Spross et al (2015), which was found to have strong correlations with local BMD and more recently described by Frank et al (2020) as a predictor of secondary displacement in non-operative patients. Our study investigates the inter-observer and intra-observer reliability of DTI and the correlation between DTI and BMD in patients with PHF. Methods: This was a cross-sectional study with retrospective review of electronic records of patients with PHF in a single hospital in Singapore. After Institutional Ethics Committee approval was obtained, we reviewed parameters such as gender, age and dual energy x-ray absorptiometry (DEXA) BMD measurements. DTI was assessed on anterior-posterior shoulder radiographs of the injured shoulder by 4 trained observers. Inter-rater and intra-rater reliability of DTI measurements were assessed and its correlation with BMD was estimated. Results: Eighty-seven patients, consisting 69 women and 18 men were recruited into the study. Mean age was 69.7 (SD 9.52, range 39 to 92) years, mean DTI was 1.49 and mean T score was -2.27 and -1.38 for femoral neck and lumbar spine on the DEXA BMD. Both the estimated intra-rater (correlation coefficient >0.80) and inter-rater reliability of DTI (intraclass correlation coefficient 0.898; 95% CI 0.784 -0.950) were considered to be good. Moderately good to poor correlations (0.40–0.580) were observed between the DTI and BMD measurements after age and gender adjustment, with the highest correlation being in the femoral neck density. Conclusion: We propose the use of DTI as a simple decision making tool that is reliable at different levels of training which strengthens its applicability in clinical practice for predicting failure of fixation of proximal humerus fracture fixation and secondary displacement of fractures in conservatively managed cases. However, our study does not support the use of DTI in predicting systemic osteoporosis.

P042: 1-Year Survival and Geriatric Syndromes in Hip Fracture: A Multi-Center Study in Mexico

D. A. Castro Rodríguez ^*1 , A. L. Saldivar Ruiz ² , C. E. Montoya Cossio ³ , E. Y. Villanueva Muñoz ⁴ , C. M. Robles Ahumada ¹ , and J. A. Diaz Ramos ¹

¹ Unidad de Atención Geriátrica de Alta Especialidad, Guadalajara, ² Instituto Nacional de Cancerología, Ciudad de Mexico, ³ Instituto Mexicano del Seguro Social HRZ 4, Nuevo Leon, ⁴ Instituto Mexicano del Seguro Social UMF 110, Guadalajara, Mexico

Introduction: In Mexico, has been estimated that up to 18% of women and 5% of men over 50 years of age will have a hip fracture throughout their lives, predicting a 7-fold increase in incidence by 2050. The consequences of a hip fracture can be catastrophic, severely affecting the mobility, quality of life and morbi-mortality of the older adults (OA). Due to the expected increase in disability, institutionalization, and mortality associated with hip fracture, it is important to investigate potentially modifiable risk factors. Methods: A cross-sectional study was carried out (January 2015 to December 2018) in which information was obtained on some geriatric syndromes and therapy for hip fracture in OA, at 2 different times during hospitalization (admission and discharge) in 3 second and third level care centers in Mexico. A multivariate logistic regression was performed to determine a risk association between 1-year survival and some geriatric syndromes. Results: 158 subjects were included (mean age 82.8 years, standard deviation ±7.63) and 70.3% were women. The combined in-hospital mortality was 7.6%, and the 1-year survival of the 3 centers was 86.7%. The multivariate logistic regression showed a significant risk association between 1-year survival and malnutrition (odds ratio [OR] 0.33, 95% confidence interval [CI], 0.12–0.92), comorbidity (OR 0.31, 95% CI: 0.10–0.99), and polypharmacy (OR 0.36, 95% CI: 0.14–0.94). The most prevalent geriatric syndromes were falls, urinary incontinence, and malnutrition. Conclusion: Malnutrition, comorbidity and polypharmacy decreased the probability of 1-year survival. This result adds to the previous evidence that places a Geriatric evaluation as a diagnostic strategy with the potential to reduce adverse events, including disability and death in OA with hip fracture. Longitudinal studies are necessary to establish the nature of these associations.

P043: Usefulness of the Nottingham Hip Fracture Score in Predicting Long-Term Mortality and Functional Health Status Decline After Hip Fragility Fracture in Brazil

K. B. G. Barbato ^*1 , F. Souza ¹ , L. F. Oliveira ² , A. P. Souza ¹ , J. Silva ³ , G. Alves ² , and R. Buksman ¹

¹ Área de Medicina Interna, ² Área de Ortopedia, Instituto Nacional de Traumatologia e Ortopedia, ³ Escola de Medicina Souza Marques, Rio de Janeiro, Brazil

Introduction: Brazilian studies show 15–50% mortality rates at the first year after hip fracture with more than 30% suffering functional deterioration. The Nottingham Hip Fracture Score (NHFS) was developed in the United Kingdom in 2007. Due to its ease of implementation, there is a suggestion that NHFS is clinically best suited for predicting mortality and it also predicts functional outcomes. We evaluated the NHFS in predicting the risk of death and functional health status (FHS) decline in hip fragility fracture patients at 18 months of follow-up. Methods: Observational study including elderly patients diagnosed with osteoporotic hip fracture in Brazil. On admission, all patients were rated by the NHFS and the preoperative FHS was classified in independent and partially or totally dependent, according to the ACS NSQIP. The continuous variables were described by mean ± SD or median [IQR], conforming to the distribution pattern. Patients were categorized into two groups using the cutoff value corresponding to the median of the NHFS. Mortality and FHS decline rates were assessed at 18 months of follow-up. Comparison between groups was performed using the chi-square or Fisher's exact test. Survival analysis with Cox regression model was performed to assess risk of death at 18 months related to the group with the highest NHFS on admission. Results: A total of 54 consecutive patients were included, 83% women, mean age 76.1 ± 8.7 years. The median of NFHS was 5 [3–6]. Patients were categorized as NFHS >5 (higher score) or ≤5 (lower score). A total of 43 (80%) patients were followed up until the end of the study or death outcome. Two (3.7%) patients died during the hospitalization. The accumulated mortality in 18 months was 18.6% (8/43); 5/11 (45.5%) in higher score group and 3/32 (9.4%) in lower score, P = 0.017. The risk of death at 18 months was 6-fold in patients with a higher score (HR 6.1 – 95% CI 1.5–25.7, P = 0.015). Additionally, among survivors, 6/6 (100%) of higher score individuals had FHS deterioration vs 10/29 (34.5%) of lower score group, P = 0.005. Conclusion: NHFS > 5 was a predictor of mortality and FHS decline in patients with osteoporotic hip fracture after 18 months of follow-up. The use of practical scoring systems that classify individuals on severity and functional disability scales can be useful not only during hospitalization, but also for better planning and post-discharge follow-up.

P044: Delirium in Fracture Femur Patients as a Cause of Prolonged Hospital Stay and Delayed Rehabilitation and to Introduce a Concise Multi-Disciplinary Assessment Form to Improve Practice

A. S. Chitnis ^*1 , and V. Borkar ¹

¹ Medicine for Older People, Buckinghamshire Healthcare NHS Trust, Aylesbury, UK

Introduction: Delirium has a high incidence among geriatric patients of about 10–15% at admission which rises to a 5–40% as an inpatient, especially post-operatively. It prolongs the duration of hospital stay, increases carer requirement and has a long-term impact on the cognition. It is a major financial burden on the NHS. This study was therefore undertaken to assess the compliance of delirium assessment in patients under the care of Orthogeriatrics admitted with a fracture femur. The aim was to identify the influence of delirium on hospital stay and rehabilitation. As a process to improve practice a multi-disciplinary delirium assessment form was introduced as a tool to improve pratice. Methods: Data was collected retrospectively from Fracture Femur pathway booklets, clinical and operative notes to identify the patients admitted with Fracture femur and had a suspicion or confirmed diagnosis of Delirium with an aim to identify the compliance to Nice best practice guidelines, influence of delirium on duration of hospital stay and rehabilitation. After a comprehensive teaching session and introduction of multi-disciplinary Delirium assessment form, a repeat audit was carried out. Results: The compliance with the Abbreviated Mental Test Score (AMTS) was a 100% on admission. The incidence of delirium was found to be about 42.85% in patients with fracture femur. Compared to an average of 16.5 days of hospital stay, patient diagnosed to have delirium had a prolonged stay of 19.9 days. About 58.33% had either an error or incomplete post-operative 4AT delirium assessment. Despite such a high incidence, the documentation of delirium on discharge summary for the GP remained 16.66%. After the introduction of the multi-disciplinary delirium assessment proforma, the compliance with 4AT increased from 78.57% to 90%. The correlation to delirium improved from 50% to 71.43%. Conclusion: The study suggested that delirium is one of the important factors prolonging stay and delaying rehabilitation in patients with Fracture femur. It also identified that a multidisciplinary delirium assessment proforma improves practice by increasing compliance with the assessment tools such as AMTS and 4AT leading to early diagnosis of delirium thus, facilitating timely intervention and preventing delay in rehabilitation. To ensure vigilance towards actively diagnosing Delirium, a section was introduced in the daily Ward Round of the Medicine for Older People.

P045: Expanding Orthogeriatric Care Beyond Hip Fractures: A Pilot Trial For Major Non-Hip Lower Limb Fragility Fractures

T. H. I. Chua ^*1 , R. Ramason ² , W. H. W. Koo ¹ , W. L. S. Tai ¹ , and L. T. Ku ¹

¹ Orthopedic surgery, ² Geriatric Medicine, TAN TOCK SENG HOSPITAL, Singapore, Singapore

Introduction: Orthogeriatric care for hip fractures has demonstrated resounding success over past two decades. Until recently, non-hip fragility lower limb fractures had been largely excluded from orthogeriatric care. Several recent studies showed that this group of fragility fractures contribute significantly to healthcare and socioeconomic burden with loss of quality of life and excess mortality exceeding that of hip fractures. As a leading centre in orthogeriatric care, we expanded our multi-faceted highly protocolised orthogeriatric care to include major non-hip lower limb fragility fractures. Methods: Admitted patients with major non-hip lower fragility fractures (femur, patella, tibia, ankle, periprosthetic, peri-implant, acetabulum) aged 60 years and older were targets for orthogeriatric intervention. Key data (length of stay, inpatient mortality, 30-day readmission, complications) on these patients was collected during the 4-month pre-intervention (Usual Care group) and 5-month post-intervention (Orthogeriatric Care group) period. Secondary outcomes tracked were falls assessment, bone health evaluation, inpatient referrals, and discharge destination. These outcomes were compared between the 2 groups. Results: Both groups were comparable in mean age and proportion of patients operated. Operated patients had shorter length of stay of almost 2 days under orthogeriatric care (Orthogeriatric Care 9.8 days, Usual Care 12.1 days). Patients in Orthogeriatric Care group had fewer complications (Orthogeriatric Care 0.1 per patient, Usual Care 0.28 per patient) with relative risk reduction of 64%. In the Orthogeriatric Care group, all patients received falls assessment, more had completed assessment of bone health, and higher proportion discharged to community hospital for rehabilitation. There were no differences in inpatient mortality, 30-day readmissions and number of inpatient referrals across the 2 groups. Conclusion: Orthogeriatric care should be expanded to major lower limb fragility fractures, resulting in better care, shorter acute hospital stays and fewer complications.

P046: Can Age Be Used to Track the Association With Mortality in Older Women in the Postoperative Period of Fractures of the Proximal Third of the Femur?

A. Pinto ^*1 , L. S. M. Pereira ² , N. Avelar ³ , G. Gomes ² , and A. Leopoldino ⁴

¹ Hospital Unimed, ² Fisioterapia, Universidade Federal de Minas Gerais-UFMG, Belo Horizonte, ³ Ciencias da Saude, Universidade Federal de Santa Catarina, Ararangua, ⁴ Fisioterapia, Faculdade Ciencias Medicas de Minas Gerais, Belo Horizonte, Brazil

Introduction: Fracture of the proximal femur is an important cause of mortality in the elders. Several conditions are characterized as risk factors for increased mortality, such as comorbidities, leukocytosis, absence of reconstructive surgery, as well as age group. However, the literature only presents increasing age as a risk factor for mortality, not delimiting a cut-off point in age for screening mortality after surgery for fractures of the proximal third of the femur. Objectives: To determine a cutoff point in age that associates with mortality in older women after surgery for fractures of the proximal femur. Methods: Retrospective cohort study and older women (≥ 60 years) with fractures of the proximal femur who underwent surgical repair treatment at a private hospital in MG, Brazil, from November 2014 to December 2019 were included. Older women with incomplete records and those with other associated fractures. The Receiver Operating Characteristic Curve was used to analyze the sensitivity and specificity of age for mortality screening and the Chi-square test to verify the association between the variables. Results: The cutoff point that best tracks mortality in elderly women after surgery for fractures of the proximal femur was age >83 years [AUC: 0.71 (95% CI: 0.673 to 0.738)]. The chi-square test of independence showed an association between age and mortality in elderly women [X2(1) = 13.064; p ≤ 0.001]. Conclusion: Age over 83 years is associated with mortality in elderly women after surgery for proximal femur fracture.

P047: How Age and Gender Influences Proximal Humerus Fracture Management in Patients Over Fifty

A. Patel ^*1 , W. Sherman ¹ , S. Ofa ¹ , J. Wilder ¹ , M. Iloanya ¹ , F. Savoie ¹ , and O. Lee ¹

¹ Department of Orthopaedic Surgery, Tulane University School of Medicine, ² Department of Orthopaedic Surgery, Louisiana State University Health Sciences Center, New Orleans, USA

Introduction: Although nonoperative management remains the mainstay of treatment for proximal humerus fractures, operative procedures may vary amongst different age groups with unclear variation between genders. Therefore, this study aimed to evaluate the trends in acute management of proximal humerus fractures in females compared to similarly aged males to determine how definitive treatment selection has changed over the last decade. Methods: Patient records between 2010 and 2019 were retrospectively reviewed from a large U.S. nationwide database to identify rates of proximal humerus fracture treatments according to gender. Patients were further stratified by age into two cohorts, patients 50 to 64 years old and those aged 65 and older. Data was queried to identify rates of closed reduction percutaneous pinning (CRPP), hemiarthroplasty (HA), intramedullary nailing (IMN), open reduction internal fixation (ORIF), total shoulder arthroplasty (TSA), reverse total shoulder arthroplasty (RSA), or nonoperative treatment. A Cochran-Armitage test was used to determine significant decade trends. Multivariate logistic regression was used to calculate odds ratios (OR) to determine which operations females were at a higher risk of receiving compared to males. Results: From 2010 to 2019, the rates of CRPP, HA, and IMN decreased while the rates of RSA and nonoperative treatment increased for both genders in the age 50 to 64 cohort (all P < 0.05). Additionally, males in this age group had an increase in the rate of ORIF (P = 0.025). When comparing females to similarly aged men, females aged 50–64 were significantly more likely to receive HA (OR: 1.16) and TSA (OR: 2.14) throughout the decade and significantly less likely to receive ORIF (OR: 0.77) and RSA (OR: 0.74). Over the decade, in the 65 and older cohort, there was a decrease in the rates of CRPP, HA, IMN, ORIF, and TSA while the rates of RSA and nonoperative treatment increased for both genders (all P < 0.05). In the 65 and older cohort, females compared to males were significantly less likely to receive CRPP (OR: 0.52), HA (OR: 0.51), IMN (OR: 0.75), ORIF (OR: 0.59), TSA (OR: 0.51), and RSA (OR: 0.42) throughout the decade. Conclusion: There were three times more females than males who sustained a proximal humerus fracture in both examined cohorts. For both cohorts and genders, there was at least a two-thousandfold increase in the rates of RSA from 2010 to 2019. As females aged, they were less likely to undergo all operative treatments compared to males.

P048: The Forgotten Fracture – Fragility Fractures of the Pelvis: Patient Demographics, in-Hospital Management and Outcomes

G. Goode ^*1 , and G. Major ²

¹ Geriatric Medicine,, ² Rheumatology, John Hunter Hospital, New Lambton Heights, Australia

Introduction: Fragility fractures of the pelvis (FFP) are a common and increasing fracture type in our aged population^1,2. There is little research describing their characteristics, management and outcomes, especially within Australia. The aim of this research was to describe local patient demographics, investigation and current management and assess outcome. Methods: A retrospective study was conducted from Jan 2017 to June 2017 to identify patients with FFP aged >50 years who were admitted to a large, tertiary, Level 1 trauma hospital in regional NSW. The medical records were analyzed to gather risk factors, patient demographics, investigation, management and outcome. Results: 60 patients with FFP were identified, average age 83 years, women represented four times more than men. All fractures occurred following a fall. 70% were from home and almost 50% mobilised with nil aids. All patients received x-ray with 73.3% proceeding to CT. Osteoporosis treatment was limited, 2/3 did not receive an anti-resorptive. Management was largely conservative with only 3 surgeries, all in the setting of additional acetabular fracture. Mean length of stay (LOS) in the acute hospital was 9.2 days, with complications significantly impacting LOS; mean LOS with complication was 13.0 days vs 7.4 days (P = 0.0039). Despite rehabilitation no patients were able to mobilize independently at discharge. Mortality was significantly impacted; 23.3% died within 12 months of fracture. Conclusion: FFP are not benign injuries and are associated with significant morbidity and mortality. There are identified areas of under-investigation and management within our population. Understanding the impact of this fracture is crucial to effective health care expenditure and patient outcomes.

P049: Osteoporotic Trochanteric Fracture Treatment With Proximal Femoral Nail

E. Selmani ^*1

¹ University Trauma Hospital Tirana Albania Service of Orthopedics and Trauma, University of Medicine Tirana, Albania, Tirana, Albania

Introduction: Osteoporotic trochanteric fractures in elderly are increasing in the last decades as the population is getting older and more active. The purpose of the study is to evaluate the functional and radiographic outcome of proximal femoral nail in treatment of proximal femoral fracture and to show common technical, mechanical complications and intraoperative difficulties during the implant implementation. Methods: We conducted a prospective study with 50 cases of osteoporotic proximal femoral fractures in elderly during the period October 2017 and October 2019 treated in our Institution surgically with proximal femoral nail fixation. Fractures were classified according to classification AO and Boyd-Griffin. Cases were followed up at regular intervals and final assessment at one year was done according to Harris hip score. Results: In our study the mean age was 69 years old. There were 35 females and 15 males included. Mean operation time was 120 minutes. Mean hospitalization day was 6 days. Union was achieved 49 cases. One case needed reoperation due to malunion in varus position. According to Harris hip scoring system there were 50% excellent results, 40% good results and 10% poor results. Conclusion: Our study showed that proximal femoral nail is a very effective technique and implant for the treatment of osteoporotic trochanteric fractures in elderly. It allows earlier weight bearing, minimal incision and blood loss and earlier rehabilitation. The implant can safely be used by an average trauma surgeon. Operation is technically not difficult and short learning curve for the surgeon.

P050: One Year Mortality and Factors Affecting it in Patients With Fracture Neck of Femur in Negara Brunei Darussalam

K. C. Pande ^{*1, 2} , D. F. Z. binti Pg Ismail ³ , and H. Abdul Rahman ³

¹ RIPAS Hospital, ² Adj Asso Prof, ³ PAPRSB Institute of Health Sciences, Universiti Brunei Darussalam, Bandar Seri Begawan, Brunei Darussalam

Introduction: Fracture of neck of femur is common among the elderly in Brunei Darussalam. While the 1 year mortality and factors affecting it have been extensively studied across the world, such information is not available for Brunei Darussalam. This study aimed to assess the mortality after neck of femur fracture and analyse various variables including gender, age, type of fracture, co-morbidities, time delay and ASA grade related to mortality. Methods: In a retrospective study, data on elderly patients with a fracture neck of femur admitted to the tertiary referral centre from January 2014 to December 2018 was analysed. Eligibility of patients include those aged 60 and above, and admitted with fragility fracture of the neck of femur. Patients with the ICD-10 diagnosis codes of S72.0, S72, S72.1 were identified and relevant information was obtained from Bru-HIMS (Brunei Health Information and Management Systems) database. Results: Over the study period 353 patients were recorded with fracture neck of femur and 222 were found eligible for the study. A median of 53 cases were recorded annually for a population of approximately 421,300 (in 2017). The mortality at 1 year was 19.4% (51/222) and higher in women (70.6%). The most common co-morbidities were hypertension, type 2 diabetes mellitus and hyperlipidaemia. Surgical delay of more than 7 days (42% of cases) and higher ASA grades were significantly associated with higher risk of mortality. The reasons for delay in surgery were for optimization of patient, stoppage of anti-coagulants and in some cases availability of Operating Room facility. Conclusion: In agreement with the literature, the 1 year mortality after fracture of neck of femur was 19.4% and was significantly related to delay in surgery and higher ASA grade. Efforts are being made to reduce the delay to the internationally recommended time frame through a multidisciplinary team lead by Geriatricians.

P051: Managing a Vaccinated Versus a Non-Vaccinated COVID 19 Positine Diagnosed Elderly Patient Who Had Sustained Intracapsular Neck of Femur Hip Fracture Challenges and Complications

A. P. Apostolopoulos ^*1 , E. Antonogiannakis ¹ , S. Lainas ² , S. Maris ¹ , S. Angelis ¹ , A. Vasilopoulou ¹ , and S. Kyriakopoulos ¹

¹ Orthopaedic, ² Surgery, Red Cross Hospital, Athens, Athens, Greece

Introduction: hip fractures in elderly patients have been associated with high morbidity and mortality rate and are dependent on the presence of associated comorbidities. SARS-CoV-2 disease (Covid-19) is nowadays considered to be an independent risk factor increasing mortality rates. The aim of our report was to analyse the management of a vaccinated versus a non-vaccinated elderly patient that were both diagnosed positive to SARS-CoV-2 after having sustained an intracapsular neck of femur fracture. Methods: Two patients (Patient A 91 and Patient B 88 years old, both female) were referred to our hospital after sustaining an intracapsular neck of femur hip fracture as a result of low energy trauma. Both patients tested positive for Covid-19 during their preoperative screening tests. Patient A had not been vaccinated against Covid-19 in contrast to patient B who had completed the 2 dose regimen of the Pfizer–BioNTech COVID-19 vaccine. Patient A presented on arrival Leukopenia (WBC: 1.2 μc/l, Neutrophils 0.4 mcL ) and Thrombocytopenia (PLT 70.000 ). The Procalcitonin, C-Reactive Protein and Ferritin levels long as Arterial blood Gases were measured in both patients on arrival. Patient A required administration of Granulocyte colony stimulating factor and platelet transfusion prior to surgery. Results: Both patients underwent uncemented hip hemiarthroplasty. Patient A was operated 5 days after hospital admission as optimization of the patient’s Covid -19 related Leukopenia and Thrombocytopenia was required and Patient B was operated within 24 hours after hospital admission. Patient A required transfusion of 4 blood Units (bleeding related to Thrombocytopenia) compared to 2 blood units that were administered in Patient B. Patient A developed Covid 19 related Pneumonia and Lung disease on the 6^th post-operative day (PO2 SO2 ) and required high flow nasal cannula therapy for 7 days followed by oxygen therapy for 8 days delaying her mobilization and hospital discharge. Patient A was discharged on the 29^th post-operative day and Patient B was discharged on the 6^th post-operative day. Conclusion: Covid 19 related complications in elderly hip fracture patients are challenging and require multidisciplinary approach and hospital resources. However, Vaccination against covid-19 seems to prevent Covid related complications and can improve the outcome. Large series studies and further research is required to support our thesis.

P052: Risk Factors in Developing Delirium in Acute Hip Fracture Patients

S. Maini ^*1 , and M. Lid ¹

¹ Geriatrics, Aalesund Hospital, Aalesund, Norway

Introduction: Orthogeriatric care is well established in Norway with most units based on orthopaedic wards. In May 2020 we established our own multidisciplinary orthogeriatric unit located on the elderly care unit. All patients >65 years (or multi morbid <65) with hip fracture are admitted to the unit. It is well recognised that delirium is a serious condition which is very common in hip fracture patients and increases the risk of short and long-term complications as well as mortality. Causes of delirium tend to be multifactorial and therefore it is difficult to identify which risk factors are important to focus on with the aim of reducing incidence. We conducted a retrospective study of consecutive patients admitted to our orthogeriatric unit with the focus on what risk factors increase the risk of delirium. The aim of the study was to identify which modifiable risk factors we can focus on to reduce the rates of delirium. Methods: We collected and analysed data from consecutive patients admitted to our orthogeriatric unit from the 4^th May 2020 till 15^th June 2021. Results: A total of 225 patients were admitted during the study period; 67.6% female with a mean age 84 years old (range 63–98 years) and 50% over 85 years old. 96.4% were operated and average length of stay was 5.7 days. 50.7% live at home independently, 15.6% were admitted from nursing homes and 27.6% had dementia. Average time till surgery is 23.3 hours and 65.4% operated within 24 hours. 43% had delirium during admission. Delirium rates were similar in men (41.1%) and women (44.1%). Delirium was more common in older patients, 22.9% in <75 years, 35.1% in 75–85 years and 56.6% in >85 years. Delirium was more common in patients with dementia (77%) and those admitted from nursing homes (69%). Anaesthesia method (43% with general anaesthetic and spinal) had no effect on delirium rates but early operation carried higher risk of delirium (45.5% with operation <24 hours vs. 37.9% with >36 hours). Polypharmacy had higher delirium risk (48.2% with >5 medications daily vs. 37.8% with 5 or less). Pre-operative femoral block had little effect on delirium rates (44.4% with block vs. 40.3% without). Conclusion: Our data suggests that most factors that affect rates of delirium are non-modifiable. We have standardised pre- and post-operative routines for pain management, nutrition and early mobilisation. We think it is now important to assess other modifiable factors such as degree of mobilisation and nursing staff levels are of significance.

P053: Use of Tranexamic Acid Reduces Postoperative Transfusion Rates in the Hip Fracture Surgeries in a University Teaching Hospital

E. Geary ^*1,2 , G. Sheridan ¹ , P. Carroll ¹ , J. Kirwan ^1,2 , K. Blake ^1,2 , J. O'Toole ¹ , M. Jonson ² , E. Scanlon ¹ , P. Keeling ¹ , and C. Hurson ¹

¹ Trauma and Orthopaedic Surgery, St Vincent's University Hospital, ² UCD School of Medicine, University College Dublin, Dublin, Ireland

Introduction: Optimising the care of patients with hip fractures to enable early mobilization and a return to pre-fracture independence, whilst reducing morbidity and mortality, is a challenge the international orthopaedic community. The introduction of perioperative tranexamic acid (TXA) has been reported to lead to an overall improvement in hip fracture care. However, there is a paucity of evidence in the literature to support this. This study aimed to assess the benefits and adverse events associated with a perioperative dose of TXA in hip fracture patients undergoing surgery at St Vincent's University Hospital (SVUH). Methods: This is a single-centre retrospective cohort study of hip fracture surgeries over one year (August 2019 to August 2020). Two groups were included in the study. Patients undergoing hip fracture repair surgery who received (intervention group) and did not receive (control group) perioperative TXA were identified. Confounders between the two groups were controlled using univariate and multivariate analysis. TXA. Outcomes assessed included intraoperative and postoperative transfusion frequency and haemoglobin levels pre-operatively and up to five days post operatively. Results: A total of 351 patients were included, 178 in the control group and 173 in the TXA group. After controlling for confounding variables on multivariate analysis (procedure type, Age, TXA, ASA and preop Hb), both preoperative Hb (P < 0.0001) and TXA (P = 0.047) were found to be predictive for reduced postoperative transfusions rates. Intraoperative transfusion was found to not be predictive in this study (P < 0.0001). With regards to postoperative venous thromboembolic events (VTE), there was found to be no statistically significant increase in the rate of VTE with the use of TXA deep venous thromboembolism (DVT) P = 0.242, pulmonary embolism (PE) P = 0.242). Conclusion: This study illustrated that perioperative TXA was found to significantly reduce postoperative transfusion rates while not increasing the rates of VTE.

P055: Factors Affecting Mortality in Nonagenarian Population Following Surgery for Fragility Hip Fractures: An Experience From a Tertiary Level Trauma Centre in India

S. Mittal ^*1 , D. Goyal ² , A. Jain ¹ , and V. Trikha ²

¹ Orthopaedics, JPNATC, AIIMS, ² Orthopaedics, AIIMS, New Delhi, India

Introduction: Fragility hip fractures in nonagenarian patients pose a great challenge in management, as the patients frequently suffer from multiple co-morbidities and functional impairment. To the best of our knowledge, no study has been previously published evaluating the outcomes and risk factors for mortality after hip fractures in this population subgroup from the Indian subcontinent. Methods: A retrospective study was performed on nonagenarian patients (aged ≥ 90) who underwent surgery for hip fractures between March 2016 and March 2019. Patients with pathological fractures, high velocity injuries and those whose records were not or partially available were excluded from the study. The patients were divided into two groups: “survivor group” (Group A) and “mortality group” (Group B). The demographic data, type of fracture, side of fractured limb, pre-injury ambulatory status, American Society of Anaesthesiologists (ASA) grade, co-morbidities, time-interval from injury to surgery, operative time and length of hospital stay were recorded from hospital medical records and were studied between the two groups. Results: Thirty-four patients were included in the study. Both the groups (A & B) had 17 patients each. Cardiac dysfunction was the most common cause of mortality. Upon analysing the variables, the time interval from injury to surgery, gender and post-operative mobility status were found to be significantly different between the 2 groups. No significant difference in ASA grade, co-morbidities, fracture type, pre-injury ambulatory status, operative time and length of hospital stay was seen between the two groups. Conclusion: Risk factors for mortality after hip fracture surgery in the nonagenarian population are male gender, delay in surgery (>3 days) and poor ambulatory status in the post-operative period. Hence, the aim for such patients with hip fractures should be to perform an early surgery and encourage an early ambulation.

P056: Retrospective Audit of Rates of Intraoperative Hypotension During 183 Hip Fracture Surgeries

C. McNamee ^*1

¹ Medical Student, Saint Vincents University Hospital, Dublin, Ireland

Introduction: Spinal and especially general anaesthesia are both associated with decreased blood pressure. In 2014, it was found that 79% of patients experienced an intraoperative fall in mean arterial pressure to below 70 mmHg. An intraoperative MAP below 75mmHg has been shown to increase 5 day and 30 day mortality. Additionally, as cumulative hypotensive time increases, so too does morbidity. The patient group undergoing hip fracture surgery is frequently elderly, hypertensive and comorbid. All of these factors increase their risk of development of hypoperfusion related sequelae post operatively. Methods: The guidelines I audited against were produced by the Association of Anaesthetists and are as follows: In 100% of patients’ lowest MAP during surgery were to be above 70mmHg. In those whose MAP falls below this value, in 100% it should be for a duration under 5 minutes. I investigated the 200 most recent hip fracture patients seen by the orthopaedics team since 08/06/2020. I obtained a list of these MRNs and other relevant information. I looked up each on the Meta Vision system where blood pressure measurements and other operative data are recorded every 5 minutes during surgery. Using excel, I made record, for each patient, if MAP had dropped below 70mmHg at any point and if so, for how long. In cases where information was missing, I excluded the patient from the audit. Results: Of the 183 patients analysed, 73% [134] had a drop in MAP pressure to below 70mmHg at some point during surgery. In 85% of these patients [114], MAP fell below 70mmHg for greater than 5 minutes, with an average duration of 17 minutes. Spinal anaesthesia was more frequently utilised than was general anaesthesia [65%, 119 times]. SA with a nerve block [34 patients] resulted in the lowest rates of hypotension with MAP falling below 70mmHg 56% of the time compared with a 88% rate of low MAP seen with GA with a nerve block [34 patients]. Conclusion: In both cycles of the audit, is has been shown in the majority of hip fracture operations, blood pressure is falling too low and when this occurs it is usually for too long a duration. Research shows, it is difficult to achieve full adoption of new guidelines as there exist barriers that slow the implementation of change. This is reflected in the results of this re-audit. In summary, concordance with AAGBI blood pressure guidelines has not improved due to some combination of personal, guideline-related and external factors. 

P057: Using Swansea Hip Interrogation Fracture Tool to Predict the Occurrence of Post-Operative Hypotension

T. Fleming ^*1 , N. Anwyll ¹ , and C. Daly ¹

¹ Orthogeriatrics, Somerset NHS foundation Trust, Taunton, UK

Introduction: The National Emergency Laparotomy Audit recommends admission to critical care for patients with a mortality of more than 10% but there is no similar recommendation for patients with femoral fractures. The Swansea Hip interrogation Fracture Tool (SHiFT) which is calculated by combining Clinical Frailty score and Nottingham hip score was recommended as a potential tool to help aid surgical resource allocation. In Musgrove Park Hospital, we treat 475 femoral fractures annually, with up to 50% of patients having some degree of post-operative hypotension. Therefore, the aim of your study was to assess if combining frailty and Nottingham hip fracture score could help predict the likelihood of post-operative hypotension and need for critical care, and thus help aid future resource allocation. Methods: A retrospective review of patients admitted with a hip fracture between January 2018 and December 2019. The date of discharge, the date of death if applicable, age, the clinical frailty score, the Nottingham Hip fracture score, the presence of hypotension as defined as 2 or more readings below a systolic of 100, and admission to critical care were collected. The SHiFT scores were collated and applied to the mortality, hypotension, and critical care data. Results: 103 case notes were reviewed with an age range of 65 to 98 years old. The SHiFT scores ranged from 2 to 16. 25.2% had a score between 2 and 8, 50.5% had a score between 9 and 12, and 24.3% had a score of more than 13. The annual mortality rate of the whole group was 26%, for scores between was 15%, scores 9–12 was 20%, scores 13–16 was 50%. There were 50 cases of post-operative hypotension with only 6 cases going to critical care. 36 patients who had post-operative hypotension were alive at one year. The SHiFT scores for patients with hypotension ranged from 4 to 15, 100% had a score of 4, 71% had a score of 5, 0% had a score of 6 or 7, 50% had a score of 8, 10, 13 or 15, and 0% had a score of 16. The 6 patients who were admitted to critical care scores ranged from 9 to 15. Conclusion: One of the limitations of this data is the small patient numbers so we are unable to identify accurate associations. The data does help to identify if there are any immersing patterns which a larger cohort would confirm. The data demonstrated that there is potentially link between annual mortality and SHiFT score, but there is no correlation between the SHiFT and the presence of post-operative hypotension, and thus the potential requirement of critical care beds.

P060: Transfusion of Blood Products in Periprosthetic Hip Fractures

M. Molinedo ^*1 , P. Vicente ¹ , I. Berasategi ¹ , and N. Cartiel ¹

¹ Hospital San Jorge, Huesca, Spain

Introduction: The increase in the number of hip arthroplasties, together with the increase in life expectancy, makes periprosthetic hip fractures increasingly frequent events in our environment. This type of fracture entails a wide series of problems, such as comminution, bone loss, loosening of the stem, in addition to the associated comorbidities of the patient. As we already know, the femur is one of the most important bones in the human body and one of the most bleeding, hence the importance of performing serial blood tests on these patients since the amount of blood they lose so much at the time of fracture as in the immediate postoperative period after osteosynthesis can have devastating results for the patient's life. Methods: We conducted a review of the cases of periprosthetic hip fracture treated in the last 6 years in our department. The information was collected through the review of the electronic medical record (OMI-AP®) and the data were analyzed through the SPSS statistical program. Results: 53 periprosthetic hip fractures treated in our department in the last six years were reviewed. The mean age of the patients was 79 years. 60% of the cases were women. The majority of fractures were type B, according to the Vancouver classification. The fractures were divided according to the Vancouver classification into three groups, observing by means of a statistical analysis (Pearson's Chi-square) the relationship between the type of fracture and the need for transfusions with a statistical significance (p) of 0.002. Thus, 100% of patients with Vancouver type C periprosthetic hip fracture required blood transfusion, while only 29.3% of patients with type B fracture received transfusions. Mortality in the first year after surgery was 15.1%. Conclusion: Periprosthetic hip fractures have a multitude of comorbidities, one of which is the large consumption of blood products. This can be a potential cause of death; therefore, depending on the type of periprosthetic fracture, a greater or lesser need for transfusion of the patient can be expected. Perioperative hematological controls are necessary in patients to avoid a catastrophic outcome.

P061: Surgical Delay in Hip Fracture

M. Molinedo ^*1 , P. Vicente ¹ , I. Berasategi ¹ , and N. Cartiel ¹

¹ Hospital San Jorge, Huesca, Spain

Introduction: Hip fracture has an incidence in our community of 750 per 100,000 inhabitants. It usually requires surgical treatment, which is often delayed due to the general conditions of the patients. One of the main reasons for delaying it is taking antiplatelet or anticoagulants. Methods: We conducted a retrospective study of the fractures operated on in our hospital in one year with a follow-up for twelve months. The results obtained after dividing the patients into two groups are described: taking antiplatelets/anticoagulants and no taking. The two groups are compared by analyzing: days of stay, Hemoglobin and Hematocrit on admission after surgery and on discharge, transfused red blood cell concentrates, complications and death. Statistical analysis with SPSS 20. Results: Final sample of 135 patients (10 were excluded). Anti-plateleted group: 57; non-antiplateleted group: 78. Average age of 83 years.80% are women. 97% required surgical treatment. 45% of antiplatelet patients die within a year. 2.74 times higher risk (1.4–5.3) of dying taking antiplatelet drugs. 3 times higher risk (1.1–9.6) of presurgical transfusion in antiplateletes group. .There is no more Risk (0.56–1.29) of postoperative transfusion. Increasing the pre-surgical stay increases mortality (P < 0.001). Conclusion: Hip fracture is a big problem in elderly patients. Taking anticoagulants or antiplatelets, increasingly present in this type of patient, leads to a longer surgical wait time, a greater need for transfusions and an increase in mortality. An attempt should be made to delay surgical intervention as little as possible, to minimize the risk of complications. There can be no justification for delaying fracture fixation by taking acetylsalicylic acid. In any case, it should not take more than 3 days.

P062: Clinical and Radiological Outcomes of Teriparatide Application in Patients With Sacral Insufficiency Fractures

D. Begkas ^*1 , S. T. Chatzopoulos ¹ , G. Geogrgiadis ² , A. Balanika ³ , and A. Pastroudis ¹

¹ 6th Orthopaedic Department and Osteoporosis Department, ² 4th Orthopaedic Department and Osteoporosis Department, ³ Deparment of Computed Tomography and Department of Osteoporosis, Asclepieion Voulas General Hospital, Athens, Greece

Introduction: Sacral Insufficiency Fractures – SIF are common in osteoporotic patients and their frequency will continue to increase with the increase of the aging population. Prolonged immobilization due to pain may result in increase of morbidity and mortality. This study aimed to evaluate the clinical and radiological effects of Teriparatide (TPD) treatment in patients that sustained an isolated Sacral Insufficiency Fracture (SIF). Methods: Between 2016 and 2017, 9 female patients where admitted in our clinic following an SIF. All patients were treated initially with bed rest and gradual mobilization within a month from the injury (as tolerated), analgesics, vitamin D supplements (25kIU p.o/week), calcium supplement (1000mg p.o/day) and 20μg/day s.c Teriparatide starting within two weeks from the injury. The follow up was at 1, 3, 6 and 12 months after the fracture and the evaluation was based upon radiological criteria (plain X-ray and C/T), clinical criteria (Visual Analog Scale – VAS), Bone Mineral Density (BMD) measurements and Bone Turnover Markers (P1NP and CTX). Results: The mean patient age was 76.5 years (67–82). All the patients showed significant reduction of pain at one month after the initiation of treatment (IoT) and remarkable improvement in their mobility at 3 months after IoT. Their mean VAS value after IoT (14.3mm) was greatly reduced in comparison with before IoT value (92mm) (P < 0.003). All fractures but two showed radiological signs of porosis, the latter two had sclerotic changes at the fracture. BMD values showed no statistical significant change. P1NP and CTX showed a marked increase at 6 months after IoT. Conclusion: In patients sustained a SIF, treatment with Teriparatide is a viable option as it may improve the functional and radiological outcome as well as it will reduce the risk of further osteoporotic fracture.  

P063: Effect of Bisphosphonate Administration Starting Time on Healing of Osteoporotic Intertrochanteric Fractures

D. Begkas ^*1 , G. Geogrgiadis ² , S. T. Chatzopoulos ¹ , A. Balanika ³ , and A. Pastroudis ¹

¹ 6th Orthopaedic Department and Osteoporosis Department, ² 4th Orthopaedic Department and Osteoporosis Department, ³ Deparment of Computed Tomography and Department of Osteoporosis, Asclepieion Voulas General Hospital, Athens, Greece

Introduction: Early use of bisphosphonates is thought to inhibit callus bone remodeling in cortical bone and delay fracture healing in patients with osteoporosis by inhibiting osteoclast function. For this reason, the optimal time to consider bisphosphonate (BP) therapy remains controversial. The purpose of this study was to investigate the effect of initial BP administration time on bone healing and to identify the best administration time after surgical treatment of osteoporotic intertrochanteric fractures (OIF). Methods: During the period 2006 and 2016, three hundred and four patients (304 hips: 102 men and 202 women) who underwent intramedullary nailing after OIF were analyzed retrospectively. Patients were divided into three groups according to the time of BP administration postoperatively (po): 1 week p.o. (group A: n = 108), 1 month p.o. (group B: n = 104) and 3 months p.o. (group C: n = 92). Their clinical evaluation was based on preoperative Koval scores and change of Koval scores 1 year p.o. The determination of fracture union time was based on radiological (calluses of the bone along the fracture line in anteroposterior and lateral radiographs) and on clinical criteria (absence of pain during hip movement). Results: The average follow-up period was 52.4 months. Koval scores one year p.o. for groups A, B, and C were 2.48, 2.40, and 2.47, respectively (P = 0.887). The mean time of fracture union was 12.8, 12.3, and 12.7 weeks p.o., respectively (P = 0.881). There were 1, 3 and 4 cases of fracture fixation displacement, respectively, but the distribution did not show a significant difference (P> 0.480). There was no case of fracture nonunion. Conclusion: The time of onset of BP administration after surgery does not affect clinical outcomes in patients with OIF.

P064: Treatment Outcomes of Teriparatide Application in Osteoporotic Patients With Pelvic Fragility Fractures

D. Begkas ^*1 , G. Geogrgiadis ² , S. T. Chatzopoulos ¹ , A. Balanika ³ , and A. Pastroudis ¹

¹ 6th Orthopaedic Department and Osteoporosis Department, ² 4th Orthopaedic Department and Osteoporosis Department, ³ Deparment of Computed Tomography and Department of Osteoporosis , Asclepieion Voulas General Hospital, Athens, Greece

Introduction: The number of patients with osteoporotic fractures is increasing annually and mainly concerns older postmenopausal women. Along with the increased number of elderly patients with severe osteoporosis, more and more cases of pelvic fragility fractures (PFFs) are being reported, which are more often found in the areas of the sacrum and pubic rami. The aim of this study was to evaluate the clinical features and therapeutic effects of teriparatide (TPD) use in patients with PFFs. Methods: Between 2014 and 2016, 32 patients (26 women and 6 men) with PFFs were treated in our clinic and their medical records were checked retrospectively. They all suffered from osteoporosis and their mean value of T-Score in the lumbar spine was -3.8 (range -2.9 to -5.8). In all cases, the diagnosis of fractures was based on plain radiographs (PR) and computed tomography (CT) of the pelvis. Additional MRI and bone scintigraphy tests were needed in 4 and 8 cases, respectively, to confirm the diagnosis. Patients were treated conservatively with bed rest and gradual mobilization within one month of injury (as tolerated), analgesics, vitamin D (25kIU p.o / week), and calcium (1000mg p.o / day) supplements. In 14 cases, TPD (20μg / day s.c.) was administered within two weeks of injury. Post-fracture patient follow-up was initially performed every 4 weeks for the first 6 months and every 3 months thereafter and was based on radiological (PR and/or CT) and clinical (Visual Analogue Scale of Pain/VAS) criteria. Results: The mean patient age was 76.8 (69–83) years. PFFs were located: in the sacrum and the pubic rami together (6 patients), in the sacrum (12 patients), in the pubic rami (14 patients). In one case where there was a fracture displacement and pain exacerbation at 4-week follow-up, it was performed percutaneous sacro-iliac fixation with cannulated screws. The duration of fracture healing was significantly shorter in patients using TPD (P < 0.05). The mean value of VAS was also lower in patients receiving TPD, however, there was no statistically significant difference with the others. Conclusion: In osteoporotic patients with pelvic pain and without major injury, we should always suspect the presence of PFFs. While conservative treatment has been shown to be adequate, in this study it appears that PTH treatment reduces time of fracture union and could be a favorable treatment option.

P065: Comparison on the Prognostic Value of News, Mews and ISS Score in Emergency Trauma Fracture Patients

J. Yang ¹ , Z. Wu ^*1 , P. She ¹ , and L. Peng ¹

¹ Xiangya Hospital of Center South University, Changsha, China

Introduction: Correctly assessing the patient's injury is of great significance. To compare the prognostic value of the British National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), and Trauma Severity Score (ISS) on the prognosis of orthopedic trauma patients, we can guide the trauma patient's care, predict the outcome of trauma patients, and evaluate the quality of care. Methods: Eighty-nine patients who were hospitalized in the Department of Orthopaedics Xiangya hospital from January 2021 to March 2021 were selected as the research objects. The general clinical data of the patients were collected, the vital signs after the consultation were recorded, and the NEWS, MEWS and ISS score were assessed. The 28-day prognosis of patients was divided into the death group, the survival group, and the transferred to ICU group. According to the scoring standards, patients were divided into less injury group, severe injury group and critical injury group. The receiver operating characteristic curve (ROC) was used to evaluate and analyze the prognostic value of the three scores and compare them. Results: The higher the NEWS score and ISS score, the higher the risk of death; there were statistical differences between the three groups. Conclusion: The NEWS, MEWS and ISS scales have clinical value in evaluating the prognosis of trauma orthopedic emergency patients. And the NEWS, which can provide timely warning of the deterioration of the patient's condition and enhance the rapid rescue response ability of medical staff and improve the treatment of trauma success rate, has the highest evaluation value among the three scales.

P066: Healfast Study: Assessment of Healing With the use of Fibrin Glue as an Adjunct in the Surgical Treatment of Non-Union

J. Ng ^*1 , E. B. K. Kwek ² , and R. Kunnasegaran ³

¹ National Healthcare Group, ² Orthopaedic Surgery, Woodlands Health, ³ Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore

Introduction: Non-union of long bones is a common challenge in the treatment of fractures. Bone grafting is commonly used to treat atrophic non-union, but mechanical displacement of the graft may occur, which may result in delay or failure of treatment. Fibrin glue has demonstrated positive results in management of bone defect in neurosurgery and oromaxillary facial surgery, however there has yet to be any study on its effects in orthopaedics long bone fractures. Methods: We conducted a prospective randomized control trial at single tertiary center involving adult patients with long bone fractures that had undergone non-union and requiring bone grafting only. Autologous iliac crest bone graft was applied to the debrided non-union site, with additional fibrin glue applied for the intervention arm. Patients were followed-up with serial radiographs until clinical and radiographical union. Results: 10 patients (3 male, 7 female), of mean age 41.7 (19–63) were recruited over 5 years, with 1 drop out. 8 out of 9 fractures united after treatment. 1 patient underwent hypertrophic non-union requiring re-fixation and bone grafting. There was no difference in the time to union for patients in the fibrin glue group (19.5 weeks) with the control group (18.75 weeks) (P = 0.86). There were no complications sustained from usage of fibrin glue. Conclusion: Fibrin glue appears to be a safe adjunct for treatment of non-union of long bone fractures across varying fracture sites and helps facilitate provisional fixation of bone autograft without impeding rates of union.

P067: Many 30-Day Readmissions of Older Patients With Hip Fracture Are Emergency Ward Visits!

M. T. Kristensen ^*1,2 , T. K. Aasvang ³ , P. B. Iheme ³ , and N. B. Foss ⁴

¹ Departments of Physical Therapy and Orthopedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, ² Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg-Frederiksberg and Department of Clinical Medicine, University of Copenhagen, Copenhagen, ³ Department of Orthopedic Surgery, ⁴ Department of Anaestesiology, Copenhagen University Hospital, Amager-Hvidovre, Hvidovre, Denmark

Introduction: 30-day readmission rates in the Capital Region of Denmark reported by The Multidisciplinary Hip Fracture Registry ranges from 21 and 29% (2018 report) and 15 and 19% (2019). Differences might be related to whether emergency ward visits are included. We examined total readmission rates including emergency ward referrals within 30 days of discharge among elderly patients with a hip fracture. Methods: Total of 687 consecutive patients aged ≥65 years discharged after treatment of an acute hip fracture at a university hospital between Jan 2018 and June 2019, were included. A readmission was defined as any hospital contact with physical attendance, and patients were followed until death or 30-days post-discharge. Date of readmission, place of “residence” at this time, cause and length of readmission were obtained from patient charts at the study hospital. Results: Total of 220 (32% in 2018 and 31% in 2019) patients were readmitted within 30 days. Their median (IQR) age was 82 (76–89) years, 135 were women, 166 came from own home, 100 had a trochanteric fracture and 142 had an ASA grade≥3. Their acute care stay was a median of 8 (6–11) days post-surgery, and time to readmission was median 8.5 (4–18) days. Fifty-six (25%) and 89 (40%) of these patients, respectively, came from a nursing home and other 24-hour settings (“rehab”). Length of readmission stays were median 1 (0–6) day, and distributed as; 0 (emergency ward), 1, 2 and 3 days for, respectively, 89 (40%), 27, 18 and 14 of patients. Sixty-five (73%) of patients with an emergency ward visit came from a nursing home or other 24-hour setting. Readmissions were related to many potential or confirmed reasons; the most prominent being a new fall, hip fracture related pain, pulmonary, gastrointestinal, infection and luxation of arthroplasty. Conclusion: One third of patients with hip fracture aged ≥65 years were readmitted within 30 days post-discharge and almost half was seen only in the emergency ward. Two thirds came from a nursing home or other 24-hour settings, and with the majority seen and handled in the emergency ward. Findings suggest that enhanced post-discharge medical attention and cross-sectorial collaboration is needed for these frail patients.

P068: Feasibility and Preliminary Effect of Anabolic Steroid in Addition to Strength Training and Nutritional Supplement in Rehabilitation of Patients With Hip Fracture: A Randomized Controlled Pilot Trial

S. Hulsbæk ^*1 , T. Bandholm ² , I. Ban ³ , N. B. Foss ⁴ , J.-E. B. Jensen ⁵ , H. Kehlet ⁶ , and M. T. Kristensen ¹

¹ Department of Physiotherapy and Occupational Therapy, ² Clinical Research Centre, ³ Department of Orthopedic Surgery, ⁴ Department of Anesthesiology, ⁵ Department of Endocrinology, Copenhagen University Hospital - Hvidovre, Hvidovre, ⁶ Section for Surgical Pathophysiology , Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark

Introduction: Anabolic steroid has been suggested as a supplement during hip fracture rehabilitation. A Cochrane Review evaluating the effect of anabolic steroids after hip fracture was inconclusive and recommended further trials. The aim was to determine feasibility and preliminary effect of a 12-week multimodal intervention consisting of anabolic steroid in addition to physiotherapy and nutritional supplement on knee-extension strength and function after hip fracture surgery. Methods: Patients were randomized (1:1) during acute care to: 1. Anabolic steroid (Nandrolone Decanoate) or 2. Placebo (Saline). Both groups received identical physiotherapy (with strength training) and a nutritional supplement. Primary outcome was change in maximal isometric knee-extension strength from the week after surgery to 14 weeks hereafter. Secondary outcomes were physical performance, patient reported outcomes and measures of body composition. Trial registration: NCT03545347. Results: 717 patients were screened and 23 randomised (mean age 73.4 years, 78% women). Target sample size was 48. Main limitations for inclusion were “not home-dwelling” (18%) and “cognitive dysfunction” (16%). Among eligible patients, the main reason for declining participation was “Overwhelmed and stressed by situation (37%). Adherence to interventions was: Anabolic steroid 87%, exercise 91% and nutrition 61%. Addition of anabolic steroid showed a non-significant between-group difference in knee-extension strength in the fractured leg of 0.11 (95% CI −0.25; 0.48) Nm/kg in favor of the anabolic group. Correspondingly, a non-significant between-group difference of 0.16 (95% CI −0.05; 0.36) Nm/Kg was seen for the non-fractured leg. No significant between-group differences were identified for the secondary outcomes. 18 potential adverse reactions were identified (anabolic = 10, control = 8). Conclusion: Early inclusion after hip fracture surgery to this trial seemed non-feasible, primarily due to slow recruitment. Although inconclusive, positive tendencies were seen for the addition of anabolic steroid.

P069: Physiotherapists Perceptions of Mechanisms for Observed Variation in Practice in Early Postoperative Phase After Hip Fracture

K. Sheehan ^*1 , B. Volkmer ² , E. Sadler ³ , K. Lambe ³ , F. Martin ³ , S. Ayis ³ , L. Beaupre ⁴ , I. Cameron ⁵ , C. Gregson ⁶ , A. Johansen ⁷ , M. Kristensen ⁸ , J. Magaziner ⁹ , T. Smith ¹⁰ , B. Sobolev ¹¹ , and C. Sackley ³

¹ Population Health Sciences, King's College London, ² Population Health Sciences, ³ Kings College London, London, UK, ⁴ University of Alberta, Alberta, Canada, ⁵ University of Sydney, Sydney, Australia, ⁶ University of Bristol, Bristol, ⁷ University Hospital of Wales, Cardiff, UK, ⁸ University of Copenhagen, Copenhagen, Denmark, ⁹ University of Maryland, Baltimore ¹⁰ University of East Anglia, Norwich, UK ¹¹ University of British Columbia, Vancouver, Canada

Introduction: To explore physiotherapists’ perceptions of mechanisms to explain observed variation in early postoperative practice after hip fracture surgery demonstrated in a national audit. Methods: A qualitative semi-structured interview study of 21 physiotherapists working on orthopaedic wards at 7 hospitals with different durations of physiotherapy during a recent audit. Thematic analysis of interviews drawing on Normalisation Process Theory to aid interpretation of findings. Results: Four themes were identified: achieving protocolised and personalised care; patient and carer engagement; multidisciplinary team engagement across the care continuum; and strategies for service improvement. Most expressed variation from protocol was legitimate when driven by what is deemed clinically appropriate for a given patient. This tailored approach was deemed essential to optimise patient and carer engagement. Participants reported inconsistent degrees of engagement from the multidisciplinary team attributing this to competing workload priorities, interpreting ‘postoperative physiotherapy’ as a single professional activity rather than a care delivery approach, plus lack of integration between hospital and community care. All participants recognised changes needed at both structural and process levels to improve their services. Conclusion: Physiotherapists highlighted an inherent conflict between their intention to deliver protocolised care while allowing for an individual patient-tailored approach. This conflict has implications for how audit results should be interpreted, how future clinical guidelines are written, and how physiotherapists are trained. Physiotherapists also described additional factors explaining variation in practice which may be addressed through increased engagement of the multidisciplinary team and resources for additional staffing and advanced clinical roles.

P070: Functional Outcomes Among Geriatric Fragility Hip Fracture Patients in a Developing Country: A Comparative Study Between Formal and Informal Post-Operative Rehabilitation

M. A. R. Peña ^*1 , I. Tabu ^{1, 2} , and D. D. Ching Bing-Agsaoay ³

¹ Department of Orthopedics, University of the Philippines-Philippine General Hospital, ² Fragility Fracture Network, Global, ³ Department of Rehabilitation, University of the Philippines-Philippine General Hospital, Manila, Philippines

Introduction: Objective: To compare functional outcomes among post-operative geriatric fragility hip fracture patients who receive formal and informal rehabilitation. Methods: Method: This is an ambispective cohort study of 50 acute fragility hip fractures over a 40-month period (October 2017 to November 2020) treated with either arthroplasty or internal fixation under the UP-PGH Orthogeriatric Fracture Liaison Service (FLS). Patients were contacted and interviewed through Telemedicine. They were asked to answer two questionnaires – the Modified Harris Hip Score (MHSS) and the EuroQol-5D—5L (EQ-5D—5L). The scores of which were tallied and used to describe and compare the post-operative functional outcomes between the two rehabilitation pathways. Results: Results: Among the 50 patients included in this study, twenty-three (46%) patients underwent formal rehabilitation, while 27 (54%) underwent informal rehabilitation. The average corrected MHSS was at 82.5 suggesting good outcomes among all patients, with a higher-than-average outcome of 83.6 among patients who underwent formal rehabilitation, and an outcome of 75.9 among patients who underwent informal rehabilitation. Results to the EQ-5D—5L survey showed that a majority of patients who underwent formal rehabilitation reported having ‘no problems’ in terms of self-care, and anxiety or depression. However, the same group had more patients reporting ‘any problems’ in terms of mobility. On the other hand, a bigger proportion of patients from the informal rehabilitation group presented with ‘any problems’ in terms of usual activities. Proportions were similar for both groups in terms of pain or discomfort, with neither group having patients who reported extreme pain or discomfort. Conclusion: In spite of the heterogenous nature of the hip fracture population, functional outcome measures show generally good outcomes of patients under the UP-PGH Orthogeriatric FLS, with no significant difference among patients who receive formal rehabilitation from those who undergo informal rehabilitation. Continuing this study may better describe and differentiate the functional outcomes in order to pave the way for evidence-based protocols dedicated to providing the highest quality of care for acute fragility fracture patients.

P071: A Clinical Audit to Review Outcomes Following Implementation of a Seven-Day Physiotherapy Service to Patients Following Hip Fracture Surgery in Saint Vincent's University Hospital

K. Byrne ^*1 , and M. Mulcahy ¹

¹ Physiotherapy, St. Vincent's University Hospital, Dublin, Ireland

Introduction: Mobilisation of patients on the day of or day after surgery by a physiotherapist has from 2020 become a clinical care standard of the Irish Hip Fracture Database (IHFD). A seven-day physiotherapy service to patients following hip fracture surgery was commenced in St. Vincent’s University Hospital (SVUH) in July 2019. The aim of this audit is to compare patient outcomes for both the year preceding and following introduction of this service. Methods: IHFD data from SVUH over a two-year period (from July 2018 to June 2020 inclusive) was analysed to allow for comparison of patient outcomes across the two time periods. Outcomes recorded were: Percentage of patient receiving a physiotherapy assessment on the first post-operative day; Median length of stay (MLOS); Percentage of patients achieving an increase of one point or more on the Cumulated Ambulatory Score (CAS) between the first post-surgery day and discharge; Percentage of patients being discharged home from SVUH post-surgery. One further outcome, to estimate the number of patients that could potentially have been discharged home from SVUH sooner than was the case, was determined through chart review. Results: 77% of patients received a physiotherapy assessment on their first postoperative day in the year preceding the seven-day physiotherapy service; this had increased to 97% in the year following. MLOS decreased to 11 days (from 14) for the year following commencement, while the percentage of patients being discharged directly home from SVUH increased by 9% in the same time period (27% vs. 18%). 61% of patients in the year preceding the seven-day service had achieved an increase of one point or more on CAS by discharge, in comparison to 59% for the year following. Chart reviews revealed 11 potentially delayed home discharges over the entire two-year time period. Conclusion: The commencement of first-postoperative-day physiotherapy input on seven days per week has resulted in an overall reduction in MLOS and increase in the frequency of day one physiotherapy assessment. There was an increase in patients returning directly home from SVUH following surgery, while chart reviews revealed 11 delayed discharges for unspecified reasons. The findings of this audit highlight the benefits of a seven-day physiotherapy service. The need for more consistent recording of CAS scores and prevention of delayed discharges is also underlined. Future audit will seek to assess for continuing compliance with best-practice guideline recommendations.

P072: Same-Day Mobilisation Following Hip Fracture Surgery

K. Byrne ^*1 , M. Mulcahy ¹ , and S. Tuffy ¹

¹ Physiotherapy, Saint Vincent's University Hospital, Dublin, Ireland

Introduction: Recent guidelines from the Chartered Society of Physiotherapy (CSP) and the American Physical Therapy Association (APTA) concerning the physiotherapy rehabilitation of patients after hip fracture surgery have recommended mobilisation on either the day of surgery, or the day following. Indeed, from January 2020 mobilisation of patients on the day of or day after surgery by a physiotherapist has become a clinical care standard of the Irish Hip Fracture Database (IHFD). To the authors' knowledge, no published research exists relating to the safety or potential benefit of same-day mobilisation after hip fracture surgery. The purpose of this study was therefore to evaluate the safety and benefit (if any) of mobilisation on the day of surgery for hip fracture. Methods: Commencing in September 2020, patients due to undergo surgery for hip fracture on weekdays in St. Vincent's University Hospital (SVUH) were assessed by the authors as to their suitability for same-day mobilisation. Inclusion criteria were: Ability to provide informed consent to same-day mobilization; cardiovascularly stable on vital-sign monitoring post-surgery; Had eaten prior to mobilization; Had recovered full light-touch sensation and active movement of the operated lower limb (in the case of spinal anaesthesia). Patients were approached by one of the authors pre-operatively to inform them of the potential of same-day mobilisation and to seek their informed consent to it. In cases where patient consent was secured, patients were mobilised post-surgery on the same day, assuming all other inclusion criteria had been met. Outcomes measured were adverse events and median length of stay (MLOS). Results: From September 2020 to March 2021 inclusive, 17 patients commenced mobilising on the day of surgery. No adverse events were recorded from this intervention. A comparison of the MLOS of same-day-mobilised patients that were discharged directly home from SVUH and the MLOS of patients in the same time period that commenced mobilising on the day after surgery and also were disharged directly home, revealed a reduction of 0.5 days in favour of same-day mobilisation. Conclusion: Same-day mobilisation after hip fracture surgery is a safe intervention that has the potential to reduce MLOS in this patient group. Same-day mobilisation will continue in SVUH in an attempt to identify those patients most likely to benefit significantly from the intervention.

P074: Anticoagulation Use and Rehabilitation Outcomes in Post-Acute Hip Fractured Patients

A. Hershkovitz ^{* 1,2} , Z. Korotkov ³ , and R. Nissan ⁴

¹ Internal medicie, Tel-Aviv university, Tel-Aviv, ² Geriatric Rehabilitation, 'Beit Rivka' Geriatric Rehabilitation center, ³ Internal medicine, Rabin medical center,, ⁴ Pharmacy, 'Beit Rivka' geriatric Rehabilitation center, Petach Tikva, Israel

Introduction: Anticoagulant drugs use may lead to delayed surgery and excessive bleeding following a hip fracture. Data as to the effect of AC use on rehabilitation outcomes amongst post-acute hip fractured patients is scarce. We assumed that AC drug use might adversely affect the rehabilitation outcome of hip fracture patients due to a possible delayed admission or other complications arising during rehabilitation. We, therefore, hypothesized that hip fracture patients receiving a full dose of AC therapy would achieve poorer rehabilitation outcomes compared with patients untreated. The objective of the present study was to examine the relationship between anticoagulant drug use and rehabilitation outcomes in post-acute hip fracture patients. Methods: A retrospective study from 1/2017 to 5/2019 of 299 hip fractured patients was conducted. Main outcome measures were the Functional Independence Measure and the motor Functional Independence Measure’s effectiveness. Results: Patients on anticoagulation drugs exhibited a significant longer latency time from fracture to surgery and from surgery to operation, and a significantly higher rate of cardiovascular diseases compared with patients who were not treated with these drugs. No significant differences between the two patient groups were found in regards to the rate of blood transfusions, perioperative complications (infections, reoperation), or functional outcome measures. Conclusion: The use of oral anticoagulants post hip fracture surgery did not negatively affect rehabilitation outcomes of hip fracture patients. Their renewal after surgery should be considered when admitted to a rehabilitation facility.

P075: Exercise Therapy is Effective at Improving Short- and Long-Term Mobility, ADL and Balance in Older Patients Following Hip Fracture: A Systematic Review and Meta-Analysis

S. Hulsbæk ^*1 , C. Juhl ² , A. Roepke ² , T. Bandholm ³ , and M. T. Kristensen ¹

¹ Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital - Hvidovre, Hvidovre, ² Department of Physiotherapy and Occupational therapy , Copenhagen University Hospital, Herlev-Gentofte, Copenhagen, ³ Clinical Research Centre, Copenhagen University Hospital - Hvidovre, Hvidovre, Denmark

Introduction: A systematic review and meta-analysis was performed to evaluate the short- and long-term effect of exercise therapy on physical function, independence and wellbeing in older patients following hip fracture, and secondly, whether the effect was modified by trial level characteristics such as intervention modality, duration and initiation timepoint. Methods: Medline, CENTRAL, Embase, CINAHL and PEDro was searched up-to November 2020. Eligibility criteria was randomized controlled trials investigating the effect of exercise therapy on physical function, independence and wellbeing in older patients following hip fracture, initiated from time of surgery up-to 1-year. Results: Forty-nine studies involving 3905 participants showed a small to moderate effect of exercise therapy at short term (end of intervention) on mobility (Standardized mean difference, SMD 0.49, 95% CI 0.22-0.76); Activities of Daily Living (ADL) (SMD 0.31, 95% CI 0.16–0.46); lower limb muscle strength (SMD 0.36, 95% CI 0.13–0.60); balance (SMD 0.34, 95% CI 0.14–0.54). At long term (closest to 1-year), a small to moderate effects were found for mobility (SMD 0.74, 95% CI 0.15–1.34); ADL (SMD 0.42, 95% CI 0.23–0.61); balance (SMD 0.50, 95% CI 0.07–0.94) and Health related Quality of Life (HRQoL) (SMD 0.31, 95% CI 0.03–0.59). Subgroup analysis indicated that strength training improves strength, ADL-training improves ADL and functional training and strength improves mobility and balance. Certainty of evidence was evaluated using GRADE ranging from moderate to very low, due to study limitation and inconsistency. Conclusion: We found low certainty of evidence for a moderate effect of exercise therapy on mobility in older patients following hip fracture at end-of-treatment and follow-up. Further, low evidence was found for small to moderate short-term effect on ADL, lower limb muscle strength and balance.

P076: 30-Day Survival and Recovery After Hip Fracture by Mobilization Timing and Dementia: A UK Database Study

A. Goubar ¹ , F. Martin ¹ , C. Potter ¹ , G. Jones ¹ , C. Sackley ¹ , S. Ayis ¹ , and K. Sheehan ^*2

¹ Kings College London, ² King's College London, London, UK

Introduction: To compare 30-day survival and recovery of prefracture ambulation between patients mobilised early (on the day of or day after surgery) and patients mobilised late (2 days of more after surgery) in England and Wales. To determine whether the presence of dementia influences the association between mobilisation timing and 30-day survival and recovery. Methods: Analysis of the National Hip Fracture Database linked to hospitalisation records for 126,897 patients ≥60 years surgically treated for hip fracture in England/Wales between 2014 and 2016. Using logistic regression, we adjusted for covariates with a propensity score to estimate the association between mobilisation timing and survival and ambulation recovery. Results: 99,667 (79%) patients mobilised early. Among those mobilised early compared to those mobilised late, the weighted odds ratio of survival was 1.92 (95% CI 1.80–2.05), of recovering outdoor ambulation was 1.25 (95% CI 1.03–1.51), and of recovering indoor ambulation was 1.53 (95% CI 1.32–1.78) by 30 days. The weighted probability (%) of survival at 30-days post-admission were 95.9 (95% CI 95.7–96.0) and 92.4 (95% CI 92.0–92.8), respectively, among those mobilised early and those mobilised late. The weighted probability of ambulation recovery given outdoor and indoor ambulation prefracture were 9.7 (95% CI 9.2–10.2) and 81.2 (95% CI 80.0–82.4), respectively, among those mobilised early, and were 7.9 (95% CI 6.6–9.2) and 73.8 (95% CI 71.3–76.2), respectively, among those mobilised late. Patients with dementia were less likely to mobilise early despite observed associations with survival and ambulation recovery for those with and without dementia. Conclusion: Early mobilisation was associated with survival and recovery for patients (with and without dementia) after hip fracture. Early mobilisation should be incorporated as a measured indicator of quality. Reasons for failure to mobilise early should also be captured to inform quality improvement initiatives.

P077: Discharge After Hip Fracture Surgery in Relation to Mobilization Timing by Patient Characteristics: A National Database Study

A. Goubar ¹ , F. Martin ¹ , C. Potter ¹ , G. Jones ¹ , C. Sackley ¹ , S. Ayis ¹ , and K. Sheehan ^*2

¹ Kings College London, ² King's College London, London, UK

Introduction: Early mobilisation leads to a two-fold increase in the odds of discharge by 30-days compared to late mobilisation. Whether this association varies by identified reasons for delayed mobilisation is unknown. Methods: Audit data linked to hospitalisation records for patients 60 years or older surgically treated for hip fracture in England/Wales 2014–2016. Adjusted proportional odds regression models tested whether the cumulative incidences of discharge differed for early compared with late mobilisation across subgroups defined by dementia, delirium, hypotension, prefracture ambulation and residence, accounting for competing risk of death. Results: Overall, 34,253 patients presented with dementia, 9,818 with delirium, and 10,123 with hypotension. Prefracture, 100,983 were ambulant outdoors, 30,834 were ambulant indoors only, 107,144 were admitted from home, and 23,588 from residential care. 10%, 8%, 8%, 12%, and 12% fewer patients with dementia, delirium, hypotension, ambulant indoors only prefracture, or from residential care mobilised early compared to those without dementia, delirium, hypotension, with outdoor ambulation prefracture, or from home. Adjusted odds ratios of discharge by 30-days for early compared with late mobilisation were 1.71 (95% CI 1.62–1.81) for those with dementia, 2.06 (95% CI 1.98–2.15) without dementia, 1.56 (95% CI 1.41–1.73) with delirium, 2.00 (95% CI 1.93–2.07) without delirium, 1.83 (95% CI, 1.66–2.02) with hypotension, 1.95 (95% CI, 1.89–2.02) without hypotension, 2.00 (95% CI 1.92–2.08) with outdoor ambulation prefracture, 1.80 (95% CI 1.70–1.91) with indoor ambulation only prefracture, 2.30 (95% CI 2.19–2.41) from home, and 1.64 (95% CI 1.51–1.77) from residential care. Conclusion: Irrespective of dementia, delirium, hypotension, prefracture ambulation or residence, early compared to late mobilisation increased the likelihood of discharge by 30-days. Fewer patients with these conditions, poorer prefracture ambulation, or from residential care mobilised early. There is a need reduce this care gap by ensuring sufficient resource to enable all patients to benefit from early mobilisation.

P078: The Role of Digital Health for Post-Surgery Care of Older Patients With Hip Fracture: A Scoping Review

J. Zhang ^*1 , Y. Ge ² , M. Yang ² , R. Ivers ^1,3 , R. Webster ^3,4 , and M. Tian ³

¹ School of Population Health, Faculty of Medicine, University of New South Wales, Sydeny, Australia, ² Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China, ³ The George Institute for Global Health, Faculty of Medicine, University of New South Wales, ⁴ Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydeny, Australia, ⁵ The George Institute for Global Health , Peking University Health Science Centre, Beijing, China

Introduction: Digital health interventions (DHIs) can improve the integration of health systems. Hip fracture is a serious injury for older people and integrated post-surgery care for hip fracture is vital for recovery. We aim to characterise DHIs used for hip fracture post-surgery care, and further to examine the extent to which of DHIs address the six domains of the World Health Organisation (WHO) integrated care for older people (ICOPE) framework. Methods: A scoping review was conducted, searching the literature from English and Chinese databases and trial registries, including Medline, EMBASE, ProQuest, PsycINFO, The Cochrane library, CINAHL, Open Science Framework, Clinicaltrials.gov, VIP, China National Knowledge of Infrastructure and Wanfang. Keywords in the English database included hip fracture, post-surgery care and digital health interventions, while Chinese keywords included “Kuan Bu Gu Zhe (hip fracture)”, “Shu Hou Kang Fu (post-surgery care)” and “Shu Zi Jian Kang (digital health)”. Interventional, observational, qualitative studies and case reports were included. We used a combined framework, the WHO ICOPE and WHO DHI classifications, to support data synthesis. Results: A total of 4,542 articles were identified, of which 39 studies were included in the analysis. We identified only six randomised controlled trials. DHIs were mainly used to help doctors provide clinical care and facilitate service delivery between the patients and health providers. No studies focused on health workforce, financial policy or the development of infrastructure. The primary users of DHIs were limited to healthcare providers and patients, with no studies involving healthcare managers or the use of data services to support the data collection, management, use and exchange. From the post-surgery care perspective, most DHIs focused on physical therapy, bone protection and falls prevention. The functionalities of DHIs were mainly limited to health promotion and providing remote services. There were limited interventions implemented in low- and middle-income countries. Conclusion: DHIs were adopted for post-surgery care of hip fracture patients, but this requires a stronger evidence base, including high-quality larger-scale studies, more focus on application in resource-constrained settings, expanding to more users and capabilities of interventions, and exploring the role of digital health for the integrated care model to mitigate health system challenges.

P-079: Inter- and Subtrochanteric vs Femoral Neck Fractures are Associated With Poorer Mobility and Physical Performance After Hip Fracture

M. A. Kujala ^*1,2 , T. Luukkaala ^3,4 , S. Stenholm ⁵ , and M. S. Nuotio ⁶

¹Department of Geriatric Medicine, Seinäjoki Central Hospital, Seinäjoki, ² University of Turku, Turku, ³ MSc, Biostatistician Research, Development and Innovation Center, Tampere University Hospital, ⁴ Health Sciences, Faculty of Social Sciences, Tampere University, Tampere, ⁵ Department of Public Health, University of Turku, ⁶ Geriatric Medicine, University of Turku and Turku University and Turku City Hospitals, Turku, Finland

Introduction: Hip fracture often leads to decline in mobility and increased need for assistance in activities of daily living (ADL). The purpose of our study was to elucidate post-fracture functional outcome and physical performance according to hip fracture type. Methods: The study material comprised all 2052 consecutive patients aged 65 and over who sustained their first hip fracture between September 2007 and February 2018 in the Hospital District of Southern Ostrobothnia, Finland. Fractures of the upper femur were categorized as neck of femur, intertrochanteric and subtrochanteric fracture. Data were collected on admission and with telephone interview by a geriatric nurse 4 months postoperatively. Follow-up visit at the geriatric outpatient clinic with comprehensive geriatric assessment (CGA) including ADL assessments was carried out 4 to 6 months post-fracture. The CGA was preceded by a physiotherapist´s examination including physical performance tests such as the Timed Up and Go (TUG), Elderly Mobility Scale (EMS) and measurement for grip strength. Logistic regression analyses were used. Results: Of the 2052 patients 62% had a neck of femur, 32% an intertrochanteric and 6% a subtrochanteric fracture. Of patient´s characteristics age, living arrangements, American Society of Anesthesiologists (ASA) grade, diagnosis of cognitive disorder and need of mobility aid were significantly associated with other hip fracture type than the femoral neck fracture. During the follow-up, mobility level had deteriorated in 39% of the femoral neck, 52% of the intertrochateric and 51% of the subtrochanteric fracture patients. Change in mobility was most significant in patients moving independently before the fracture. Advanced age and abnormal/low results in physical performance tests and low ADL performance were more common in patients with other hip fracture type than the femoral neck fracture. In the multivariable analyses adjusted for age, gender and mobility level at baseline, poor results in each of the physical performance tests and ADLs were significantly associated with intertrochanteric vs femoral neck fractures. Conclusion: Femoral neck fracture patients are more likely to regain their pre-fracture mobility level after hip fracture compared to inter- and subtrochanteric fractures but mobility decline is common in all hip fracture types. In order to regain pre-fracture mobility, all hip fracture patients need intensive rehabilitation.

P080: Setting New Irish Standards in Hip Fracture Rehabilitation

L. O Brien ^*1 , A. O Reilly ¹ , and M. McGrath ¹

¹ Physiotherapy Department, Tallaght University Hospital, Dublin, Ireland

Introduction: Hip fractures are a common result of falls in the elderly. The Chartered Society of Physiotherapist’s Standards state that these patients should receive daily physiotherapy that accumulate to two hours within seven days of surgery. The aim of this audit is to establish the benefits of a seven day hip fracture physiotherapy service versus a five day service in Tallaght Univers Hospital (TUH) using the Cumulated Ambulatory Score (CAS). The CAS is an effective outcome measure in predicting length of stay, 30 day mortality and post-operative complications (Foss et al., 2005). Methods: This audit examines the pilot seven day service in December 2021 and compares it to two previous audits completed on the five day service in 2020 on gym versus ward based rehabilitation Patients within seven days post-surgery between 07/12/2021 and 21/12/2021 were selected. Data was gathered on the average therapy contact time, CAS (patients’ ability to complete transfers and mobilise post-surgery), and number of patients seen 7/7, 6/7 and 5/7 days. Data was inputted into an Excel spreadsheet. Results: Data was collected on 21 patients. The seven-day service improved patient number of contacts. Therapy time per week accumulated to an average of 165.9 minutes. CAS scores improved significantly. The seven-day service resulted in 90.5% of patients improving their CAS versus 67% in the five-day service. The seven-day service provided 7/7 days physiotherapy to 24% of patients and 6/7 days to 33% of patients versus 0% in the five day services; 10% received 5/7 days physiotherapy versus 28% in the five day gym service and 0% in the five day ward service. Those who did not receive 7/7 days physiotherapy were accounted for being discharged within their first seven days, medically unfit, physiotherapy staffing and patient’s declining therapy. Conclusion: This audit has demonstrated improved patient outcomes with a seven day service. The most significant result was the improvement in the CAS. The service has potential to reduce hospital length of stay, post-operative mortality, complications and achieve better patient functional outcomes. The seven day physiotherapy service is now provided by TUH which reflects UK standards and warrants introduction at a national level in Ireland.

P081: Recovery of Function Following Non-Hip Non-Vertebral Fragility Fracture: A Systematic Review

S. Dyer ^*1 , N. May ¹ , T. Ross ¹ , E. Liu ² , M. Cations ³ , J. Magaziner ⁴ , and M. Crotty ¹

¹ Flinders Health and Medical Research Insitute, Flinders University, Adelaide, ² Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, ³ College of Education, Psychology and Social Work, Flinders University, Adelaide, Australia, ⁴ Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, USA

Introduction: The long-term impact of hip fracture on quality of life and function is well recognised. However, outcomes following non-hip non-vertebral (NHNV) fracture have received less attention. The aim of this systematic review is to quantify the impact of NHNV fragility fracture on World Health Organisation International Classification of Functioning outcomes of activity, participation and accommodation. Methods: Multiple databases including MEDLINE, EMBASE and PsycINFO were searched to Sept 2019. Inclusion criteria were: inception cohort studies of unselected NHNV fracture patients reporting a pre-fracture baseline, or population-based cohort studies reporting outcomes for unselected NHNV fracture and non-fracture groups; mean participant age 65 years or older; outcomes measured one month or longer after fracture. Study selection and data extraction were performed in duplicate. Risk of bias was assessed according to the STROBE statement. Results: Nine included studies reported on activity or participation outcomes. Most studies were considered of high quality. Twelve months after NHNV fracture, the percentage of people with recovery of walking mobility ranged from 65% for humerus fracture to 90% for wrist fracture (1 study, Australia, n = 570). Six months post-wrist fracture, the percentage recovering independence in basic activities of daily living (ADLs) was 76%, and 77–84% for instrumental ADLs (1 study, Spain, n = 680–976, different scales). In single US population-based cohorts, wrist fracture was also associated with a significantly greater adjusted odds of functional decline in IADLs overall (odds ratio (OR) 1.48, 95% CI 1.04–2.12, n = 6,107, mean 1.1 year post-fracture) and domestic duties (cooking OR 10.2, 95% CI 3.3–31.9; shopping OR 3.3, 95% CI 1.3–8.0; 1 study, n = 1,010; mean 7 years post-fracture), in comparison those not experiencing a fracture. Rib or ‘other’ (including pelvis, forearm) NHNV fractures were associated with a significant decrease in ambulation in women 5 years post-fracture (1 study, Canada, n = 6,603). Following humerus fracture, 18% of patients required a new admission to a nursing home on discharge from hospital (1 study, Australia, n = 281). Conclusion: NHNV fractures have a significant impact on activity, participation, and accommodation outcomes over the medium to longer term. Given their high incidence rate, the population level impact of NHNV fractures is likely to be significant and warrants further investment in falls prevention and rehabilitation strategies.

P082: Predicting Functional Outcomes in Conservatively Managed Proximal Humerus Fractures With Radiographic Evaluation

J. Song ^*1 , B. Tan ¹ , and C. J. Lim ²

¹ Orthopaedics,, ² Statistics, Tan Tock Seng Hospital, Singapore, Singapore

Introduction: Treatment of proximal humerus fractures that are minimally displaced remains controversial. Some patients that are managed conservatively can potentially have good outcomes. This paper aims to evaluate the relevance of the anteroposterior (AP) view, lateral Y-scapular view in predicting functional outcomes and to assess the intra- and inter-rater reliability of these radiographic parameters. Methods: Radiograph images were assessed for 132 patients. Caput-collum-diaphyseal (CCD) angles, Y-scapular angles, and humeral head height (HHH) were obtained from the radiographic images. The patients were split into varus and valgus groups and retroverted and anteverted groups. Functional outcome was measured by Oxford Shoulder Score (OSS), Constant Shoulder Score (CSS), and quick Disabilities of Arm, Shoulder and Hand (quickDASH) scores. Intra- and inter-rater reliability for 2 assessors were measured for all radiographic angles with the intraclass correlation coefficients (ICCs). The relationship between functional outcomes and radiographic parameters was assessed with a linear regression model. Receiver operator curve (ROC) analysis and logistic regression analysis defined the optimal value for abnormalities on radiographic evaluation as an outcome predictor. Results: The intra-rater reliability for both raters were both above 0.90. The inter-rater reliability for radiographic parameters was also generally above 0.90. There was a significant relationship between OSS and final Y-scapular angle in the retroverted group in both univariable and multivariable analysis (coefficient 0.058, 95% CI (0.008, 0.318), P = 0.025) and (coefficient 0.056, 95% CI (0.008, 0.104), P = 0.022), respectively. The optimum predictive angulation at the final Y-scapular was 25^o for predicting poor functional outcome with an area under the ROC curve of 0.611 (95% CI, 0.460, 0.761). Conclusion: This study showed that there was good intra- and inter-rater reliability for radiographic measurements of proximal humeral fractures. In addition, Y-scapular views and to a lesser extent, HHH values are the most critical in predicting functional outcomes in proximal humeral fractures.

P083: Hip Fracture Recovery: Physical Performance at 2 Months and Mobility 1 Year Post Hip Fracture

R. Bajracharya ^*1 , D. Orwig ¹ , J. Guralnik ¹ , M. Shardell ¹ , and J. Magaziner ¹

¹ Epidemiology and Public Health, University of Maryland Baltimore, Baltimore, USA

Introduction: Physical performance measures are the cornerstone for identifying older adults at a greater risk of poor outcomes like hospitalization and disability. However, the utility of physical performance measures to predict recovery after a sudden mobility disablement such as hip fracture is unclear. The objective of this analysis was to assess whether physical performance at 2 months post hip fracture can predict functional recovery one year post fracture independent of variables available from the medical chart and self-report. Methods: The study population includes participants enrolled in the Baltimore Hip Studies7th cohort (n = 339). The study endpoint was participants’ self-reported ability to walk one block. Candidate predictors of this endpoint were: 1) physical performance [Short Physical Performance Battery (SPPB), gait speed, and grip strength], 2) medical abstract variables [sex, age, ASA (American Society of Anesthesiologist) physical status rating, fracture type, surgery procedure, and comorbidities], and 3) self-reported walking (ability to walk 10 feet and 1 block pre-fracture and at 2 months). The most important predictors of functional recovery at 12 months were identified by two different methods: (1) Logistic regression followed by area under the ROC curve and Hosmer and Lemeshow goodness-of-fit test for discrimination and calibration, respectively, and (2) Classification and Regression Tree Analysis. Results: The analytic sample comprised 162 participants with complete data. Mean age was 81 years. In the fully adjusted model only 2-month SPPB score (OR = 1.59, CI = 1.25–2.02), self-reported pre-fracture ability to walk a block (OR = 4.35, CI = 1.44–13.11), and 2-month ability to walk 10 feet (OR = 3.24, CI = 1.29–8.14) predicted ability to walk a block at 12 months. The model performed well with an area under ROC curve of 0.88 and had a good fit (Hosmer and Lemeshow Chi-square p-value = 0.77). The CART model showed that individuals with a 2-month SPPB score ≥ 3 had a 71% probability of being able to walk a block at 12 months compared to only 15% probability for those who score less than 3. Conclusion: Measuring SPPB at 2 months post hip fracture in the clinical setting may facilitate a more accurate assessment of long-term functional recovery compared to typical medical status variables.

P084: Can Physical Performance Predict Long-Term Mortality Post Hip Fracture in Older Adults (65–100 Years of Age)?

R. Bajracharya ^*1 , J. Guralnik ¹ , J. Magaziner ¹ , and D. Orwig ¹

¹ Epidemiology and Public Health, University of Maryland Baltimore, Baltimore, USA

Introduction: Functional performance measures (grip strength, Short Physical Performance Battery (SPPB), and 3-meter gait speed) represent underlying disease progression and predict mortality. However, there is little information regarding whether these measures assessed at 2-months post-hip fracture predict long-term mortality (10-year follow-up). Methods: To address this gap, a longitudinal analysis of Baltimore Hip Studies-7 cohort, with mortality verified by National Death Index, was conducted. Mean difference in 2-month functional performance measures (n = 242, men n = 121, female n = 121) among those who survived and did not survive over 10 years was determined using t-test. Prediction of mortality by these measures, overall and by sex, was estimated using cox proportional hazard models, for which Hazard ratios (HR) with 95% confidence intervals (CI) were estimated. Results: We found that, gait speed [0.47 (standard deviation, SD = 0.39) versus 0.31(SD = 0.27)] and SPPB score [4.89(SD = 3.31) versus 2.83(SD = 2.24)] were significantly higher at 2 months among those surviving compared to those who did not. Adjusting for covariates, functional performance predicted long-term mortality in men and women. Increase in gait speed by 0.1m/s predicted 15% decrease in mortality for men [HR = 0.85(0.55–0.96)] and 17% for women [HR = 0.83 (0.74–0.93)]. Increase in SPPB by 1 unit predicted decrease in mortality by 14% for men [HR = 0.86(0.77–0.95)] and 17% for women [HR = 0.83(0.74–0.93). Increase in grip strength by 1 kg predicted 5% decrease in mortality for men [HR = 0.94 (0.92–0.97)] and 9% for women [HR = 0.90 (0.86–0.95)]. Conclusion: Functional performance measured at 2-months post-hip fracture predicted long-term mortality. Those with poor functional performance at 2-months can be referred for further assessment to optimize their care to promote survival.

P085: Orthopaedic Rehabilitation is Associated With Better Outcomes in Orthopaedic Patients With COVID-19

S. Murphy ^*1 , C. Henry ¹ , E. Stanley ² , and E. Ahern ³

¹ Orthogeriatric Medicine, South Infirmary Victoria University Hospital, ² Department of Geriatrics, ³ Department of Geriatric Medicine, Cork University Hospital, Cork, Ireland

Introduction: The geriatric patient cohort is at high risk of falling and sustaining a fragility fracture, leading to an admission to the orthopaedic rehabilitation ward. Outbreaks of COVID-19 on wards were a common occurrence, with 13% of cases classified as ‘healthcare acquired’. This study examines a group in whom these two scenarios coincided, those who sustained a fragility fracture, and later contracted COVID-19 during their rehabilitation stay. The study aims to identify whether access to orthopaedic rehabilitation services during the acute phase of COVID-19 was associated with better patient outcomes. Methods: A retrospective, cohort observational study was carried out. Data from 26 rehabilitation patients aged over 65 years with confirmed COVID-19 at two Irish orthopaedic rehabilitation wards were collected from health records. Symptom profile, COVID-19 severity level based on Irish Thoracic Society guidelines, Clinical Frailty Scale (CFS), Cumulative Illness Rating Scale-Geriatric (CIRS-G) scores and radiological data were reviewed and compared with outcomes from a similar study carried out in the hospital setting. Results: Patient mortality rate was 7.7% (n = 2) in the orthopaedic rehabilitation population compared to 23.2% (n = 16) in the acute hospital orthopaedic population. Median survivor age was 79.5 years (IQR 70–85.5) and 81.5 years (IQR 76.5–86.5), respectively. Mean CFS was 4.15 (SD 1.6) and 5 (SD 1.6), respectively. Mean CIRS-G scores were 10.6 (SD 4.3) and 8.19 (SD 4.4). Most patients were categorised as mild COVID-19 cases (n = 25, 96%), (n = 56, 81.1%). Eight patients (n = 8, 30.8%) in rehabilitation group were asymptomatic compared to five (n = 5, 7%) in the acute hospital group. Atypical symptom presentation was 15.4% (n = 4) and 7% (n = 5) respectively. Delirium was noted in 11.6% (n = 3) of rehabilitation patients compared to 30.4% (n = 21) of acute patients. Non-invasive ventilation was required in 3.8% (n = 1) of rehab patients and 2.9% (n = 2) of acute hospital patients. Conclusion: Orthopaedic rehabilitation patients were younger, less frail, had a milder COVID-19 disease profile and lower mortality rate when compared with orthopaedic patients in the acute hospital setting. Rehabilitation patients had lower rates of reported delirium. Rehabilitation patients’ better outcomes may have been associated with an increased accessibility to allied healthcare, increased time between sustaining a fragility fracture and being diagnosed with COVID-19 and a hospital environment more conducive to recuperation.

P086: Factors Associated With Urinary and Double Incontinence in a Geriatric Post-Hip Fracture Assessment in Older Women

A. Hellman-Bronstein ¹ , T. Luukkaala ^2,3 , S. Ala-Nissila ^4,5 , and M. Nuotio ^*1,6

¹ Division of Geriatric Medicine, Department of Clinical Medicine, University of Turku, Turku, ² Research, Development and Innovation Center, Tampere University Hospital, ³ Health Sciences, Faculty of Social Sciences, Tampere University, Tampere,, ⁴ Department of Obstetrics and Gynaecology, Turku University Hospital, ⁵ Division of Obstetrics and Gynaecology, Department of Clinical Medicine, University of Turku, ⁶ Research Services, Turku University Hospital, Turku, Finland

Introduction: Incontinence and hip fractures, both of which are more common among women than in men, are associated with numerous adverse outcomes, such as functional decline, institutionalization, and mortality. Incontinence is a known risk factor for falls. The aim of this study was to investigate the prevalence and changes of urinary incontinence (UI) and double incontinence (DI, concurrent UI and faecal incontinence) among older female hip fracture patients, and to identify factors associated with UI and DI six months post-fracture. Methods: A prospective population-based cohort study was conducted. All female patients aged ≥ 65 who were treated for their first hip fracture in Seinäjoki Central Hospital, Finland, between May 2008 and April 2018, were included. Pathologic and periprosthetic fractures were excluded. Continence status was elicited at baseline and six months postoperatively at our geriatric outpatient clinic where all participants underwent a comprehensive geriatric assessment (CGA) and a physiotherapist’s examination. Multinomial logistic regression analyses were used. Results: Of the 910 patients included in the study, 70% were aged over 80 years, 25% had a cognitive disorder, 22% lived in an institution, 33% had poor nutrition, and 37% could not ambulate independently at baseline. Before the fracture 47% were continent, 45% had UI and 8% had DI and, 38%, 52% and 11% six months post-fracture, respectively. The continence status had deteriorated in 24% of the patients. In the multivariable-adjusted analyses, constipation (odds ratio [OR] 1.48, 95% confidence interval [CI] 1.02–2.13) and depressive mood (OR 1.81, 95% CI 1.16–2.84) observed in the outpatient CGA were associated with UI, whereas prolonged use of urinary catheter during hospitalization (OR 2.33, 95% CI 1.31–4.14), non-independent mobility at baseline (OR 2.08, 95% CI 1.05–4.15) and poor nutrition observed in the outpatient CGA (OR 2.31, 95% CI 1.11–4.79) were associated with DI six months post-fracture. Conclusion: This study demonstrates a high prevalence of UI and DI in older female hip fracture patients. Both UI and DI were associated with modifiable risk factors, which should be targeted both during hospitalization and rehabilitation process as a part of secondary falls prevention. Patients with DI were found to be an especially vulnerable group. More efforts are needed to increase awareness of incontinence and its consequences and complications in older hip fracture patients.

P087: Minimal Clinical Important Difference and Responsiveness of Performance-Based and Self-Reported Measures Used in Older Adults Following Outpatient Rehabilitation Programme Post-Hip Fracture Surgery

J. A. Overgaard ^*1,2 , and M. T. Kristensen ^3,4

¹ Department of Rehabilitation, Municipality of Lolland, Maribo, ² Physical Medicine and Rehabilitation Research - Copenhagen (PMR-C), ³ Department of Physical and Occupational Therapy, Copenhagen University Hospital, Bispebjerg - Frederiksberg Hospital, ⁴ Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark

Introduction: We aimed to investigate the minimal clinical important difference (MCID) and responsiveness of both the performance-based measures of strength, mobility, and balance and also the self-reported health-related quality of life (Short Form-36 SF-36)) and function (New Mobility Score (NMS)) after hip fracture. Methods: Secondary analysis of clinical trial data using a distribution-based method including a sample of older adults (n = 88) with a mean (SD) age of 77 (8) years. They were undergoing outpatient rehabilitation two times a week for six weeks starting approximately 18 days post-hip fracture surgery. The MCID was calculated by using half of the baseline standard deviation. The responsiveness was evaluated by calculation of effect size (ES) using mean change divided by baseline standard deviation. Results: MCID values of the different measures were: Timed Up & Go (TUG) (3.5 s); 10-meter walk test (10MWT) (0.11 m/s); static balance test (2.6); NMS (0.53); Barthel-20 (0.89); SF-36 Physical (SF-36P) (4.13) and Mental (SF-36M) (5.85); 6-minute walk test (6MWT) (45.83 m); fractured limb quadriceps strength (FLQS) (0.14 Nm/kg) and non-fractured limb quadriceps strength (NFLQS) (0.23 Nm/kg). The most responsive measure was the self-reported NMS (ES 1.76), followed by performance-based measures of gait ((6MWT (ES 1.26); 10MWT (ES 1.19) and TUG (ES 0.9)). Other performance-based measures had moderate (FLQS (ES 0.70)) and small ES (NFLQS (ES 0.46); static balance test (ES 0.23)). Self-reported measure of the Barthel-20 had moderate ES (ES 0.64), while both the SF-36P and SF-36M had small ES (ES 0.43 and ES 0.15, respectively). Conclusion: Self-reported measure of function and performance-based measures of gait appear to have the greatest ability to detect the change in this sample of older adults undergoing rehabilitation early post-hip fracture surgery. Self-reported function evaluated by the 0-9 point NMS showed very low MCID and largest effect size of all measures.

P088: Activities-Specific Balance Confidence Scale (ABC) is a Potential Screening Tool For Fall Prevention in Community-Dwelling Older Adults With Less Functional Limitations: A Prospective Cohort Study

C. Tsang ^*1 , J. Leung ¹ , Z. Lu ¹ , and T. Kwok ¹

¹ The Chinese University of Hong Kong, Hong Kong, Hong Kong

Introduction: Whether balance confidence is an independent fall predictor among community-dwelling older adults remains inconclusive. Potential mediation of the different levels of functional limitations in predicting falls with balance confidence is to be explored. Methods: Balance confidence was measured using Activities-specific Balance Confidence scale (ABC) in 462 community-dwelling older adults who aged 60 to 92 years and had fallen within the previous year. Functional performance was measured by Ten-Meter Walk Test, Five Times Sit-to-Stand Test, and Physiological Profile Assessment (PPA) that examined vision, vestibular function, peripheral sensation, muscle force, and reaction time. Other potential fall predictors including age, sex, depression, cognitive deficit, uses of walking aids and multiple medications were also examined. Fall incidence was followed up trimonthly for 12 months. Factors differentiated fall status at an alpha level of 0.1 were identified as covariates. For ease of clinical application, an optimal cut-off score for differentiating subsequent fall status was identified for the ABC using Receiver Operating Characteristic curve. Covariates-adjusted fall prediction validity of the ABC cut-off score was examined. For exploring the mediation of functional limitations in fall prediction with ABC subgroup analysis was done. Subgroups of less and greater functional limitations were classified using the PPA z-score. Results: Four hundred forty-two participants (96%) accomplished the 12-month follow-up and 105 (24%) fell. The ABC cut-off score identified was 74. ABC score of 74 or less, having depression, and PPA z-score were significant fall predictors. The ABC cut-off score remained to be a significant fall predictor after adjusting for the effects of sex, PPA z-score, and the history of depression. In the subgroup analyses, the ABC cut-off score remained a significant fall predictor, together with the history of depression, only in people with less functional limitations. The PPA z-score was the sole significant predictor in those with greater functional limitations. Fallers with ABC scored 74 or less were around two folds more likely to have further falls in the subsequent 12-months (adjusted OR = 1.665–2.695, 95% CI = 1.021–5.748, P < 0.05). Conclusion: ABC is a potential self-administrated screening tool for identifying probable fallers among community-dwelling older adults with less functional limitations. 

P090: Non-Pharmacological Management of Osteoporotic Vertebral Fractures: A Qualitative Analysis of Health-Care Professional Perspectives And Experiences

N. Tibert ^*1 , S. Brien ² , L. Funnell ² , J. Gibbs ³ , R. Jain ⁴ , H. Keller ¹ , J. Laprade ⁵ , S. Morin ³ , A. Papaioannou ⁶ , M. Ponzano ¹ , Z. Weston ⁷ , T. Wideman ³ , and L. Giangregorio ¹

¹ Kinesiology, University of Waterloo, Waterloo, ² Canadian Osteoporosis Patient Network, N/A, ³ McGill University, Montréal, ⁴ Osteoporosis Canada, ⁵ University of Toronto, Toronto, ⁶ McMaster University, Hamilton, ⁷ Conestoga College, Kitchener, Canada

Introduction: Vertebral fractures are the most prevalent fractures among individuals living with osteoporosis, affecting at least 20% of the older population. Our objective was to understand health care professionals' (HCPs) experiences and perceptions of post-vertebral fracture rehabilitation, use of non-pharmacological strategies, and virtual rehabilitation. Methods: We performed a thematic and content analysis of semi-structured interviews that were conducted over web conference/telephone with HCPs within Canada. Criterion, purposeful, and snowball sampling was used to recruit HCPs that have experience treating patients with osteoporotic vertebral fractures. Questions for the interview guide were centred on current practices, non-pharmacological treatments, and virtual rehabilitation. Results: 13 HCPs (7F, 6M, aged 46 ± 12 years) were interviewed. Two major themes emerged from our interviews: (1) rehabilitation of vertebral fractures is dependent on the acuity of fracture, and (2) care gaps in referral and access to rehabilitation. Early rehabilitation interventions included pain and osteoporosis medicine, education on harmful and high-risk movements, and non-pharmacological strategies to help reduce patient pain and increase early mobilization. Rehabilitation in the chronic stage of vertebral fractures incorporated more exercise-based strategies to help increase strength, mobility and functionality and was informed by a comprehensive assessment. Regardless of the stage of recovery, barriers such as delayed identification of fracture, delayed or no referral to physiotherapy, and lack of knowledge of osteoporosis or vertebral fracture among HCPs may reduce the access to or effectiveness of non-pharmacological interventions. HCPs believed that virtual rehabilitation that includes an online educational component, an online assessment, and online exercise classes in groups tailored to individuals could be a feasible alternative. Conclusion: We have identified that rehabilitation provided by HCPs was dependent on the acuity or stability of fracture, and that non-pharmacological interventions were facilitated by physiotherapy. To select and individualize physical therapy interventions, physiotherapists emphasized using assessments to determine patient goals, physical functioning, and identify co-morbidities. To improve access and address barriers, virtual rehabilitation could be a feasible and effective alternative for patients but may require further evaluation.

P091: Thigh Muscle Composition and Its Relationship to Functional Recovery Post-Hip Fracture Over Time and Between Sexes

M. Eastlack ^*1 , R. Miller ² , G. Hicks ³ , A. Gruber-Baldini ⁴ , D. Orwig ⁴ , J. Magaziner ⁴ , and A. Ryan ⁵

¹ Department of Physical Therapy, Arcadia University, Glenside, ² Novartis Institutes for BioMedical Research, Cambridge, ³ University of Delaware, Newark, ⁴ Department of Epidemiology and Public Health, School of Medicine, ⁵ Department of Medicine, Division of Gerontology and Geriatric Medicine, University of Maryland Baltimore, Baltimore, USA

Introduction: The purpose is to investigate the relationship of muscle cross-sectional area (CSA), muscle attenuation (MA) and intermuscular adipose tissue (IMAT CSA) to functional recovery in persons post hip fracture over time and between sexes. Methods: Cross-sectional and longitudinal analyses at 2 and 6 months from a post-hip fracture cohort (Baltimore Hip Studies 7^th cohort) which purposely included equal numbers of males and females. Muscle CSA, muscle CSA difference (non-fractured side – fractured side), MA and IMAT were measured using computed tomography imaging of the mid-thigh cross-sectional region and were divided into tertile groups. Physical function was measured with the Short Physical Performance Battery (SPPB). Generalized estimating equations (GEE) were used to model the association of muscle composition and physical function. Additional variables included in the model were time and sex. Results: Seventy-one participants (52% males, age 79.6 ± 7.3 yrs) were included. Males had greater thigh CSA (P < 0.0001), higher muscle attenuation, P = 0.005) and smaller percentage of LDM, P = 0.047 and IMAT, P = 0.007 on the fractured side than females at baseline. Females were faster at performing the chair rise test (P = 0.01) and scored higher on the SPPB (P = 0.05) at baseline. Muscle CSA was associated with gait speed (r = 0.29, P = 0.03). Higher muscle CSA and MA on the fractured side was associated with better function at 2 months in both sexes. Subjects in the lowest tertile of muscle CSA difference (less atrophy on fractured side) performed better in gait speed and SPPB than the other two tertiles at 6 months post fracture. There was a significant interaction between time and IMAT CSA for gait speed (P = 0.0175) and chair rise time (P = 0.035). The trajectory in recovery in chair rise time differed between sexes (P = 0.0162) such that males performed more poorly in physical function measures at baseline and did not recover as well as females. Conclusion: CT-scan based measures of muscle atrophy and fatty infiltration were associated with functional performance at 2-months post hip fracture and with improvement in functional performance by six months’ post-fracture. Observed sex differences in these associations suggest that rehabilitation strategies may need to be adapted by sex after hip fracture.

P092: Disability Among Older Fallers With and Without Hip Fracture in Brazil: Results From the National Survey of Health

S. Câmara ^*1 , A. Cavalcante ² , Á. Maciel ¹ , and M. Mata ³

¹ Department of Physiotherapy, Federal University of Rio Grande do Norte, Natal, ² Faculty of Health Sciences of Trairi, Federal University of Rio Grande do Norte, Santa Cruz, ³ Health school, Federal University of Rio Grande do Norte, Natal, Brazil

Introduction: Hip fractures are associated with major functional limitation among older adults. However, there is a lack of national studies in Brazil that evaluates how hip fractures are associated with functional status of faller older adults. This study aims to evaluate the association between hip fracture and functional status among a national sample of over 60 years-old fallers in Brazil. Methods: This is a cross-sectional analysis from the National Survey of Health in Brazil conducted in 2013 by the Brazilian Institutes of Geographics and Statistics, in which data from 23,815 older adults from all regions of the country were collected. Information about falls and hip fractures in the past 12 months, as well as information about surgical treatment, hospitalization and about their functional ability for basic activities of daily living (ADL) (ambulating, feeding, dressing, bathing, and toileting) were collected during home-visits. Logistic regressions analyzed the associations between hip fracture and each functional activity adjusted by age, sex, ethnicity, socioeconomic position, number of medical appointments in the past year and diagnostic of chronic conditions. Results: Falls in the past 12 months were reported by 1,825 (7.7%) older adults. From those, 120 (7.0%) reported hip fractures, being mainly women (n = 85, 70.8%) and older than fallers without fracture (mean age 75.2y vs 71.9 y; P < 0.001). Surgery was reported by 42.5% (n = 51) of the hip fracture patients, and 51% (n = 26) of them reported surgery within the first 48h after the fall. Average time of hospitalization was equal to 6.9 days (SD = 5.5). Hip fracture patients present higher odds of difficulty or inability for all ADL (ambulating [OR = 3.2; 95% CI = 2.1–4.2], feeding [OR = 1.7; 95% CI = 1.1–2.8], dressing [OR = 3.0; 95% CI = 2.0–4.5], bathing [OR = 4.1; 95% CI = 2.7–6.3], and toileting [OR = 4.7; 95% CI: 3.1–7.3]), irrespective of the covariates. Higher odds of disability were associated with older ages, male sex, higher number of medical appointments and having a chronic condition in the multivariate analyses. Conclusion: Hip fracture patients present higher odds of disability in all ADL within one year after the fall. Health policies and rehabilitation strategies targeting this group should be implemented to improve their functional status.

P093: Physical Performance and Quality of Life Indices in Postmenopausal Women With Vertebral Fractures Depending on Their Quantity and Localization

O. Rybina ¹ , and N. Grygorieva ^*1

¹ Dmitry F. Chebotarev Institute of Gerontology of the NAMS of Ukraine, Kyiv, Ukraine

Introduction: Current literature review demonstrates that vertebral fractures (VFs) are ones of the most frequent and dangerous complications of postmenopausal osteoporosis, that lead not only to severe spine pain, restriction of physical activity and increased disability, but also to enlargement of mortality rate. Objectives: The aim was to assess the features of physical performance and quality of life indices in postmenopausal females with vertebral fractures (VFs) depending on their quantity and localization. Methods: We examined 230 postmenopausal women aged 50–89 years old, divided into 2 groups: 1^st one – without any previous fractures (control group), 2^d group – with VFs in thoracic and/or lumbar spine. Females from 2^d group were divided into subgroups: 2^a – with one VF; 2^b – with 2 or more VFs; 2^th – females with thoracic VFs; 2^l – women with lumbar VFs; 2^c – patients with combined VFs (thoracic and lumbar spine). The physical performance was evaluated using the following tests: 3-, 4- and 15-meter gait speed tests, five-repetition sit-to-stand test, hand grip strength, measurement of respiratory rates, breath holding, chest excursion, lateral trunk lean, Schober and Thomayer tests. Quality of life was assessed by EuroQol-5D questionnaire, disability – using Roland-Morris questionnaire. Results: It was established that lateral trunk lean, chest excursion, 15-metre test, 5-repetition sit-to-stand test and hand grip strength changed only in females with 2 or more VFs compared to indices in control group, whereas index of Schober test, breath holding are worse both in women with one or two or more VFs. The females with thoracic VFs had their indexes of breath holding and 15-metre tests changed compared to control group, whereas women with lumbar VFs had worse indices of Schober test, lateral trunk lean, hand grip strength and five-repetition sit-to-stand test in comparison with control group. The indices of lateral trunk lean, chest excursion, 15-metre test and hand grip strength in patients with combined VFs are significantly worse compared to control group. Conclusion: The indices of physical performance depend on VFs quantity and localization that should be accounted in assessment of physical performance and development of rehabilitation programs for females with VFs. Quality of life indices were worse in females with 2 or more or combined VFs.

P094: Impact of Psychological Factors on Walking in Older Adults Following Hip Fracture

R. Fortinsky ^*1 , G. Soliman ¹ , K. Mangione ² , B. Beamer ³ , L. Magder ³ , E. Binder ⁴ , R. Craik ⁵ , A. Gruber-Baldini ³ , D. Orwig ³ , B. Resnick ³ , and J. Magaziner ³

¹ UConn Center on Aging, University of Connecticut, Farmington, ² Physical Therapy, Arcadia University, Philadelphia, ³ University of Maryland, Baltimore, ⁴ Washington University , Saint Louis, ⁵ Arcadia University, Philadelphia, USA

Introduction: Community-dwelling older adults experiencing hip fracture often fail to achieve adequate levels of physical function following surgery and rehabilitation. Effects of psychological factors on walking capacity following hip fracture are understudied. Therefore, the objective of this study is to investigate effects of psychological resilience and depressive symptom severity on walking outcomes in older adults following hip fracture. Methods: Data were drawn from the Community Ambulation Project, a clinical trial of 210 community-dwelling adults aged >60 who experienced a minimal trauma hip fracture randomized to one of two 16-week home-based physical therapy interventions within 26 weeks post-hospital admission for surgical repair. For this analysis, the Brief Resilience Scale (BRS) was grouped into quartiles and CES-Depression (CESD) Scale was dichotomized at <16 or >16; both were measured before randomization (baseline). Walking measures, including 4-Meter Gait Speed (4MGS), 50-Foot Walk Test (50FWT), and Six-Minute Walk Distance (6MWD), were assessed at baseline and 16 weeks later. In longitudinal regression analyses where 16-week values of each of these walking measures were dependent variables, covariates included trial arm, gender, age, and baseline values of the following: the walking measure corresponding to the dependent variable, body mass index, optimism (Life Orientation Test-Revised), cognitive status (3MS), informal caregiver need, days from hospital admission to randomization. Results: After adjusting for covariates, mean increases over 16 weeks in 4MGS, 50FWT and 6MWD were 0.07m/s (P = .03), 0.11m/s (P < .01), and 28.7m (P = .03) greater, respectively, in the highest quartile BRS group than in the lowest quartile BRS group. Mean increase in 4MGS was 0.05m/s greater in the CESD<16 group than in the CESD>16 group (P = .04). Conclusion: A higher level of psychological resilience was associated with greater improvements in walking speed and distance. Fewer depressive symptoms were associated with greater improvement in walking speed at short distance. Interventions that enhance psychological resilience and decrease depressive symptoms may improve walking performance following hip fracture.

P096: Mobility Following Femoral Neck Fracture Surgery: Does Surgical Treatment Affect Physiotherapy Outcome?

S. Mcshane ^*1 , E. Mc Cabe ¹ , H. French ² , A. Glynn ³ , and A. Bisseru ³

¹ Physiotherapy, HSE, Drogheda, ² Physiotherapy, RCSI, Dublin, ³ Orthopaedics, HSE, Drogheda, Ireland

Introduction: Many patients sustaining hip fracture do not regain their pre-injury function. Early rehabilitation improves outcome. The aim of this study was to investigate if hip fracture patients progressed differently following surgery depending on whether arthroplasty or internal fixation (IF) was employed. This information may be useful to identify patient cohorts who may require further rehabilitation prior to discharge home. Methods: A prospective database was used to audit outcomes for hip fracture patients presenting to our unit between October 2019 and October 2020. Our study group comprised 89 patients with femoral neck fractures. 60 patients were female, 29 were male. Average age was 77 years (range 50–96). 69 patients were treated by arthroplasty, 20 patients were treated with IF. The group treated by IF were younger (mean 71. 4 years) compared to the group treated by arthroplasty (mean 79.3 years) (P = 0.0027). Timed Up and Go (TUG) test was performed as soon as patients were able to complete same post-operatively, and again at discharge, to assess difference over time. Results: 17 patients out of 20 (85%) of the group treated with IF were able to perform a TUG test prior to discharge, at a mean of 4.3 (range 2–13) days post-operatively. Mean time taken to complete an initial TUG by the IF group was 74.7 seconds. Of the patients treated with arthroplasty, 54 out of 69 (78%) were able to complete a TUG prior to discharge, at a mean of 4.9 (range 1–16) days. The mean time taken to complete the initial TUG by a patient treated with arthroplasty was 87.8 seconds. By discharge the time taken to complete this distance had reduced in both groups with the arthroplasty group completing their TUG in a mean of 46 seconds (median 39 seconds) and the IF group completing the TUG in a mean of 55.7 seconds (median 46 seconds). Twenty-six (38%) of the patients treated with arthroplasty were discharged home directly, while eleven (55%) of the patients treated with IF were discharged home directly. Conclusion: Hip fracture patients treated with arthroplasty had lower functional ability on day one post-operatively compared to the IF group, however patients treated with arthroplasty showed the greatest improvement in function and mobility at the time of discharge. Despite this, a greater proportion of the IF group were discharged directly home (55% vs 38%) and able to receive any ongoing rehabilitation as an outpatient while the majority of the arthroplasty group required further inpatient rehabilitation.

P097: Increased Male Mortality After Hip Fracture in Cognition- and Infection-Related Causes of Death

H. Mutchie ^*1 , R. Bajracharya ¹ , D. Orwig ¹ , A. Gruber-Baldini ¹ , M. Hochberg ² , and J. Magaziner ¹

¹ Department of Epidemiology and Public Health, University of Maryland, Baltimore, ² Department of Medicine, University of Maryland Baltimore, Baltimore, USA

Introduction: Mortality after hip fracture remains high, approximately 30% in the first three months. Males are known to have worse mortality outcomes overall and among hip fracture patients compared to females. Infection and Alzheimer’s disease and related dementia (ADRD) are among the top three causes of death among hip fracture patients. This study aimed to measure sex differences in survival time and mortality risk among hip fracture patients who died of infection- or cognition-related causes of death (COD). Methods: Patients, age 65 and older, were recruited within 15 days of hospitalization for surgical repair of hip fracture (2006–2011). COD and date of death were derived from the National Death Index (December 2018). Complete cases(N = 330; 145 Male, 155 Female) were assessed using Cox Proportional Hazards models to determine the adjusted Hazard Ratio(HR) for all-cause and cause-specific mortality risk by patient sex; adjusted for age, education, comorbidities, depression, and American Society of Anesthesiologists Physical Status Rating. Results: The sample was majority white with a mean age of 80.8 (7.7) years, and approximately 50% female. There was not a significant age difference between males and females. Median overall survival time was 46.7 months (42.3 males, 54.6 females). Of the 267 reported deaths 62 (30 male, 32 female) were cognition-related, and 38 (25 male, 13 female) were infection-related with 6 (4 male, 2 female) cross-over cases. Median survival time for cognition-related COD was 54.2 months (43.8 male, 61.7 female) and was 25.3 months for infection-related COD(17.0 male, 54.6 female). Males had significantly greater risk of all-cause mortality (HR = 4.8, 95% CL: 2.5, 9.4). Males were also at increased risk for cognition-(HR = 1.60, 95% CL: 1.2, 2.2) and infection-related COD (HR = 1.5, 95% CL: 1.1, 2.1) in both crude and adjusted analyses. Conclusion: Known sex differences in mortality risk after hip fracture remain. Within the most common causes of death there are increased risks of mortality for males compared to females after hip fracture. While males had increased mortality risk in all conditions, median time to death was noticeably shorter for infection-related COD. These findings continue to highlight the negative outcomes for males after hip fracture. Despite the increased risk there are positive aspects to this work including that median time to death was still multiple months after the initial fracture and could mean that there is room for survival extending measures to be employed.

P098: Prognostic Factors of Depression After Hip Fracture Surgery: Systematic Review

R. Milton-Cole ^*1 , S. Ayis ¹ , K. Lambe ¹ , M. O'Connell ¹ , and C. Sackley ¹

¹ Department of Population Health Sciences, King's College London, London, UK

Introduction: Patients with hip fracture and depression are less likely to recover. This review aimed to identify prognostic factors of depression up to one year after hip fracture surgery in adults. Secondary aims were to determine whether identified factors are modifiable or non-modifiable and describe proposed underlying mechanisms for their association with depression. Methods: We searched MEDLINE, Embase, PsychInfo, CINAHL and Web of Science Core Collection databases for published studies. We searched OpenGrey, Greynet and BASE and conference proceedings for unpublished studies. We identified any further relevant studies from the reference lists of included studies. We did not impose any date, geographical, or language limitations. Two reviewers independently screened studies against predefined eligibility criteria to identify relevant papers. We included observational studies investigating prognostic factors of depression up to one year after surgery in adults surgically managed for non-pathological hip fracture. We resolved conflicts by consensus. Two reviewers independently extracted data (Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies, adapted for use with prognostic factors studies Checklist) and completed quality appraisal (using Quality in Prognosis Studies tool). We resolved conflicts by consensus. Results: 3,402 studies were identified, 2,915 studies were excluded leaving 13 studies included in this review. 3,769 patients were included across all studies with a mean age ranging from 76.21 to 81.82 years. A total of 39 prognostic factors were investigated and most studies failed to identify a primary prognostic factor of interest. Most of these factors were patient factors with only a few being process or structure factors. Conclusion: Various potential prognostic factors of depression after hip fracture were identified; however, methodological quality and heterogeneity between studies limited the certainty of which prognostic factors were the strongest. High-quality research investigating prognostic factors using the same study design, methodology and measurements is warranted to allow for comparisons of the predictive power of factors, as well as future research into the underlying mechanisms of prognostic factors.

P099: Postoperative Rehabilitation and Functional Outcome of Fragility Hip Fracture in University Malaya Medical Centre (UMMC) Malaysia

H. T. Lim ^*1 , T. I. W. Ong ¹ , H. M. Khor ¹ , C. S. K. Chandrasekaran ² , S. S. Jagdis Singh, ² , Y. K. Adnan ² , and M. R. Draman@Yusof ²

¹ Department of Geriatric Medicine, ² Department of Orthopaedic Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia

Introduction: Up to 60% of patients are unable to regain their pre-fracture level of mobility following hip fracture despite surgical intervention. Early mobilisation is important in preventing complications of immobilisation and aiding reestablishment of pre-fracture functional status. We aim to assess rehabilitative services and functional status after surgery. Methods: We analyzed medical records of all patients under orthogeriatric care who had hip surgery admitted between 1.8.2020 and 31.10.2020. Results: A total of 42 patients with mean age of 77.8 years were recruited. Median duration from admission to operation was 4 days (interquartile range, IQR = 3) and patients spent a median of 4 days (IQR = 2) postoperatively in hospital. 22/42 (52.4%) patients were reviewed by the physiotherapist on the day after operation. Common causes for delay in physiotherapy were the lack of services out-of-hours (14/20) and delays in referral process (4/20). Only 10/42 patients (23.8%) were mobilized the day after surgery and other reasons for the delay were uncontrolled pain (3/32), anaemia (2/32) and hypotension (2/32). During discharge, 27/42 (62.3%) were referred for outpatient physiotherapy. Of these, only 11/27 (40.7%) patients attended with median time to first outpatient physiotherapy session in 35 days (IQR = 19). Majority of cases (88.4%) had independent mobility prior to hip fracture. At 12 weeks post-surgery, only 18/42 (42.9%) were able to ambulate independently. 13.2% of patients resumed pre-fracture mobility status and 50.0% recovered to a lower level. Conclusion: Majority of patients experienced functional loss after hip surgery and this highlights the gap in rehabilitation services. Barriers to physiotherapy can be addressed systematically, allowing rehabilitative activities to be initiated in a timely and sustained manner. 

P100: Measuring the Impact of COVID-19 Restrictions on Mobility in Older Patients With a Fragility Fracture Using the New Mobility Score

F. O' Riordan ^*1 , J. Murphy ¹ , G. Egan ¹ , and E. Ahern ¹

¹ Department of Geriatrics, Cork University Hospital, Cork, Ireland

Introduction: The World Health Organization declared COVID-19 a pandemic in March 2020. In Ireland, public health restrictions were implemented with specific measures for older adults who were advised to ‘cocoon’ or remain at home as much as possible. While this has a positive effect on disease spread, a reduction in physical activity in older individuals even for short periods has been shown to increase the risk of falls and fractures as well as all-cause mortality. The New Mobility Score (NMS) stratifies patients with fractures according to pre-fracture mobility based on the ability to perform three activities; indoor walking, outdoor walking and shopping. The NMS is an independent predictor of in-hospital outcome and a cutoff score of 5 has been found to be a valid predictor of 6-month functional level and 1-year mortality. Using the NMS score, we evaluated patient mobility pre and post implementation of restrictions. We also obtained basic data, information on the frequency of patient falls pre and post restrictions together with Clinical Frailty Scale (CFS). Methods: We prospectively studied 50 patients admitted following a fracture and reviewed by our Orthogeriatric team at our hospital from August-October 2020. Results: The mean age was 80 years [range 53–99], over 80% (41) were over 70 years and 43 (86%) were female. A hip fracture (78%) was the most common reason for admission and the mean CFS was 4 [Range 1–7] classifying our cohort as living with very mild frailty. There was a statistically significant difference in mean NMS with a lower mean NMS post implementation of COVID-19 restrictions compared to pre restrictions; [5 [SD 2.19] vs 6.5 [SD 2.15] [P = 0.0074] ]. There was no difference in the mean number of falls pre and post restrictions [pre COVID-19; 1.1 [S.D 2.3] and post COVID-19 1.9 [S.D 1.9] [P = 0.0609]. Conclusion: Our study has shown that in a vulnerable cohort of patients, COVID-19 restrictions have significantly impacted patient mobility over a short period of time. Our results show that as result of the reduction in mobility following implementation of COVID-19 restrictions, our patients are less likely to regain pre-fracture functional level and are at a higher risk of all-cause mortality. As further public health restrictions are implemented across the world to control the spread of COVID-19, public health strategies and advice for older people should be prioritised to maintain mobility and physical activity and prevent adverse outcomes.

P101: Functional Limitation is Associated With Multimorbidity and the Use of Pain Modulators in The Elderly Undergoing Surgery for Fractures of The Femur And Distal Radius

G. W. Waldolato ^*1 , L. Pereira ² , N. Carelli Pereira de Avelar ³ , G. de Cássia Gomes ² , and A. Leopoldino ⁴

¹ Orthopaedics, Hospital Universitário Ciências Médicas, ² Fisioterapia, Universidade Federal de Minas Gerais, Belo Horizonte, ³ Ciências da Saúde, Universidade Federal de Santa Catarina, Aranguá, ⁴ Fisioterapia, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil

Introduction: To evaluate which conditions are associated with activity limitation in elderly patients undergoing femoral and distal radius surgery. Methods: Cross-sectional, retrospective study, data collected over a 5-year period, from medical records and face-to-face examination of patients undergoing surgery for fractures of the distal radius and proximal femur, at a Brazilian University Hospital (Ethically approved CAAE: 28504919500005134). The outcome of the presence of functional limitation was evaluated by the question: "After the fracture, are you able to perform all activities in a similar way as before the incident?" The variables evaluated were: gender, multimorbidity, use of pain modulator (gabapentin, pregabalin, amitriptyline), postoperative physical therapy, trauma mechanism (fall from height, fall from height[GG1] , sprain[GG2] ), use or not of analgesic, age group (60–69 years, 70–79 years and ≥ 80 years[GG3] ) and Body Mass Index (BMI) (< 22 kg.m², 22–27 kg.m² and > 27 kg.m²). Results: Twenty-five older people participated, the chi-square test of independence demonstrated an association of functional limitation and multimorbidity [X2(1) = 5,235, p: 0.022] and use of a[GG1] pain modulator [X2(1) = 5,114, p: 0.024]. There was no association with the variables: sex [X2(1) = 1.01, p: 0.315], post-surgical physical therapy [X2(1) = 0.033, p: 0.856], trauma mechanism [X2(1) = 0.777, p: 0.687], analgesic use [X2(1) = 2.482, p: 0.115], age group [X2(2) = 3.616, p: 0.164], BMI [X2(2) = 0.818, p: 0.664]. Conclusion: There was an association between the presence of functional limitation with multimorbidity and the use of pain modulator in elderly patients undergoing femoral and distal radius surgery.

P102: Do Anthropometric and Physiological Characteristics and Physical Activity Affect Bone Mineral Density and Quality of Life in Postmenopausal Women?

A. Yaman ¹ , O. Ozdemir ² , S. Gul ² , S. Karahan ³ , and Y. G. Kutsal ^*2

¹ Department of Physical and Rehabilitation Medicine, Gulhane Training and Research Hospital, ² Department of Physical and Rehabilitation Medicine, ³ Department of Biostatistics, Hacettepe University Medical School, Ankara, Turkey

Introduction: There are various factors that can affect bone mineral density (BMD) and quality of life (QoL) in postmenopausal (PM) women. The aim of this study was to evaluate the relationship of anthropometric and physiological characteristics and physical activity to BMD and QoL in PM women. Methods: One hundred eighty one PM women were included. Demographic and clinical characteristics (age, education, smoking, comorbidities, age of menopause, calcium and 25hydroxyvitaminD levels) were recorded. Also, anthropometric characteristics including height, weight, body mass index(BMI), waist-to-hip ratio (WHR), digit ratio (2D:4D), skeletal-muscle-mass-index (SMI), hand and calf circumferences and physiological parameters, including handgrip strength (HGS) and balance of the subjects, were measured. The BMDs at L1–L4 total and femur neck (FN), femur total (FT) were measured by dual-energy X-ray absorptiometry device and the results were recorded. The questionnaire on physical activity[International Physical Activity Questionnaire (IPAQ)] and QoL[41-item Quality-of-Life Questionnaire of the European Foundation for Osteoporosis (QUALEFFO-41)] were assessed. Results: This study included a total of 181 PM women (mean age 62.78+7.81 years, age of menopause 45.69+5.58 and BMI 27.24kg/m²). 47% of the patients graduated from primary school while most of the participants had systemic disease(64.6%) and were non-smokers(71.8%). The mean calcium and 25 hydroxyvitamin D levels were 9.7 and 26.2, respectively. The mean SMI and IPAQ met were 9.06+1.31 and 3060+254, respectively. The mean scores of QUALEFFO-41 including pain, physical function, social function, general health perception, and mental function were 47, 33, 67, 60 and 50, respectively. Weight and BMI showed significantly positive correlation with BMDs at L1-L4 total, FN and FT. Besides, hand and calf circumferences showed significantly positive correlation with a BMDs at femur neck. However, there was no significant correlation between the HGS and BMDs. Balance was not correlated with BMDs either. When categories of IPAQ were compared in terms of BMDs, we determined no difference between three groups. There was no correlation between the BMDs and QUALEFFO-41 scores and IPAQ met. Nonetheless we detected significant correlation between HGS and QUALEFFO-41 scores. Conclusion: Bone mineral density and QoL in PM women is a multifactorial condition, and multifaceted evaluation covering the anthropometric aspect will be useful in terms of clinical practical applications.

P103: Kinesiotherapy in Surgically Treated Hip Fractures

B. Mitrevska ^*1 , V. Koevska ¹ , E. Nikolik Dimitrova ¹ , C. Gerakaroska Savevska ¹ , M. Gocevska ¹ , B. Kalcovska ¹ , and M. Manoleva ¹

¹ University Clinic of physical medicine and rehabilitation, SKOPJE, Republic of North Macedonia

Introduction: Kinesiotherapy has a major role in the rehabilitation treatment of hip fractures treated conservatively or surgically. Isometric, isotonic active exercises are applied, and then gradually resistance exercises, treadmills, push-ups, walking exercises. Magnetictherapy also plays a role in stimulating osteogenesis. The aim of this paper is to show the importance and role of kinesiotherapy and magnetictherapy in the rehabilitation of patients with surgically treated hip fractures. Methods: The study represents a prospective randomized clinical trial. Include two cohorts, with 90 participants with surgically treated pertrochanteric fracture with DHS. Respondents are divided into two groups: Examined group- 45 patients is treated with kinesitherapy and magnetictherapy and control group – which has 45 patients treated with kinesitherapy and therapy with interference currents. Measurements were made of the range of motion of the operated leg at four time points, on admission to hospital, on discharge, and at 6 and 12 months of follow-up. Results: At the physical examination after 6 and 12 months, for P < 0.05, the analysis showed that the flexion with an upright knee and the abduction in the hip in the group treated with magnetictherapy is significantly higher compared to the one in the control. After 12 months, at P < 0.05, the analysis indicated that the flexion with bent knee and hip extension in the group treated with magnetictherapy was significantly greater compared to that in the control. Conclusion: Kinesiotherapy has a positive role in stimulating osteogenesis; improving muscle strength, flexibility and coordination; improving posture and balance, and thus functional status; reducing pain and preventing recurrence and the risk of recurrent fracture.

P104: Identification of Distal Radius Fragility Fractures by the Fracture Liaison Service – A Regional Comparison Audit of Practice

S. Castagno ^*1 , A. Ngu ¹ , M. Vindlacheruvu ¹ , J. Fleming ¹ , M. Loeffler ² , and N. Kang ¹

¹ Addenbrooke’s Hospital, Cambridge,, ² Colchester Hospital, Colchester, UK

Introduction: Distal radius fractures (DRFs) are very common in older people and often result from low-energy falls in individuals with underlying osteoporosis. Fracture Liaison Services (FLSs) are designed to identify, investigate and treat patients with fragility fractures to prevent further fractures. The aim of this study is to audit an established FLS’s current practice in identifying patients aged 50 or older with fragility DRFs against the current BOAST guidelines (stating all patients should be identified), and compare it with the identification rate in an acute hospital in the same region without a dedicated FLS. Methods: All forearm and wrist radiographs of patients aged 50 or older presenting at Addenbrooke’s Hospital in the UK between 1^st April and 31^st July 2020 were assessed to identify patients with DRF. Electronic patient records were investigated to determine mechanism of injury (MoI), age, gender, admission or discharge and follow-up in fracture clinic (FC). Only low-energy MoIs were included. Results: Of 117 DRF patients (males: 8, females: 109; median age: 74yrs, age range: 51–94 yrs), 13 (11%) were not identified by the FLS. FC follow-up was strongly associated with identification by the FLS, with patients not seen in FC more likely to be missed (P < 0.0001). Although the majority of admitted patients were identified (96%), discharge did not appear to increase the risk of being missed (P = 0.163), but half those missed were on no Trauma & Orthopaedics Department list. Conclusion: Addenbrooke’s FLS is very successful at identifying DRFs. In comparison, an acute hospital with no FLS reported identifying just 2%. However, this audit highlights opportunities to further enhance FLS detection of fragility fracture patients, particularly those discharged from A&E without follow-up. Improving identification of fragility fractures will undoubtedly be beneficial to patients and financially favourable for the NHS. This study demonstrates the clear benefit of an FLS in identifying patients with fragility fractures.

P105: The Influence of Combination Therapy With Low-Dose Romosozumab and Active Vitamin D3 in Ovariectomized Rats

Y. Tsubouchi ^*1 , T. Otsu ² , R. Takase ¹ , T. Kataoka ¹ , S. Ikeda ^1,3 , M. Kataoka ⁴ , and H. Tsumura ³

¹ Department of Rehabilitation, Oita University Hospital, Yufu, ² Department of Innovative Engineering, Oita University, Oita, ³ Department of Orthopaedic Surgery, Oita University, Yufu, ⁴ Faculty of Welfare and Health Sciences, Oita University, Oita, Japan

Introduction: Most of the studies on the effects of Romosozumab in animal models used high doses, such as 25 mg/kg twice weekly, which was not a practical dose. Furthermore, there was no report on the effect of the combination with active vitamin D₃ (VitD) on bone microstructure and strength. The purpose of this study was to investigate the effects of low-dose Romosozumab and VitD combination therapy on bone microstructure and strength in ovariectomized rats. Methods: A total of 40 female Sprague–Dawley rats aged 24-week-old were divided into 4 groups (n = 10 each) after 8 weeks of ovariectomy according to interventions: Control (C group, administered saline); Romosozumab administration (R group, 25 mg/kg monthly administration); VitD administration (VitD group, 0.2mg/kg, 2 times/week) and Romosozumab + VitD administration (R + VitD group). In addition, 10 rats without ovariectomy were included as the sham group (S group). After 10 weeks of treatment, we removed the femur and evaluated bone mineral density and bone morphometry by μCT (SkyScan 1172, Kontich, Belgium). In addition, we measured bone metabolic markers by ELISA and bone strength by using a 3-point bending test. SPSS 22.0 was used for statistical analysis. Following a one-way analysis of variance, the Tukey test was performed as a post-hoc test between group comparisons. Results: The results of trabecular bone morphometry in the R and R+VitD groups, trabecular bone volume, trabecular thickness, and trabecular number were improved compared with the C group. In the cortical bone, the cortical bone thickness and cortical bone area were also improved. In addition, the R+VitD group improved compared with the R group. On the other hand, there was no difference in bone metabolic markers between the groups. In the bone strength measurement, the maximum load and Young'smodulus were improved in the R and R+VitD groups compared with the C group. Conclusion: Romosozumab improving the bone structure that activates osteoblast activity and inhibits osteoclast activity by inhibiting sclerostin. On the other hand, VitD has also been reported to improve bone structure by promoting bone formation and increasing bone density. The results of this study indicate that low-dose Romosozumab is not only effective in the treatment of osteoporosis but also improve the bone microstructure and bone strength when combined with VitD.

P106: Synergy Effect Between Milk Basic Protein and Zoledronate to Bone Microstructure and Strength in Ovariectomized Rats

T. Kataoka ^*1 , O. Takefumi ² , Y. Tsubouchi ¹ , R. Takase ¹ , S. Ikeda ^{1, 3} , M. Kataoka ⁴ , and H. Tsumura ³

¹ Department of Rehabilitation, Oita University Hospita, ² Department of Innovative Engineering, Oita University, ³ Department of Orthopaedic Surgery, Oita University Hospita, Yufu, ⁴ Faculty of Welfare and Health Sciences, Oita University, Oita, Japan

Introduction: Milk basic protein (MBP) has been reported to be effective against osteoporosis; however, the underlying details are unknown. This study aimed to clarify the efficacy of MBP and investigate the synergistic effects between MBP and zoledronic acid, which is a bone resorption inhibitor, in a rat osteoporosis model. Methods: Ovariectomies were performed on 28 24-week-old female Sprague-Dawley rats. Eight weeks after the surgery, seven mice each were assigned to the following four arms: control (C arm), spontaneous oral MBP ingestion (MBP arm), zoledronic acid administration (ZA arm), and spontaneous oral MBP ingestion in addition to ZA administration (MBP + ZA arm). Furthermore, seven sham-operated mice (S arm) were included. After 10 weeks of intervention, the animals were sacrificed, both femurs were excised, and sera were collected. Soft X-ray imaging and micro-computed tomography (CT) were performed for bone morphometry of the excised femurs. Additionally, histopathological examinations, serum bone metabolism marker evaluations, and three-point bending bone strength tests on the femurs were performed. Results: Soft X-ray images revealed no obvious differences between the arms. On the contrary, micro-CT examinations revealed cancellous bone mass increase in the order of C < MBP < MBP + ZA < ZA < S arms. Similar results were confirmed by histopathology. The analysis of serum bone metabolism markers showed almost no differences in bone resorption markers between the MBP and MBP + ZA arms; however, bone formation marker levels showed the following trend: MBP + ZA < MBP arms. Moreover, in the bone strength test, Young’s modulus was higher in the order of ZA < MBP < MBP + ZA < S arms. Conclusion: In terms of cancellous bone mass, the inhibitory effect of ZA on bone resorption was greater than that of MBP; hence, bone turnover decreased and no synergistic effect was observed. However, MBP was considered to enhance material properties (bone quality), and thus a synergistic effect was observed between MBP and ZA.As an osteoporosis treatment, MBP + ZA appears to be ineffective in terms of cancellous bone mass; however, it may be effective in terms of bone strength.

P107: Osteoporosis Education Intervention Improves Osteoporosis Knowledge of Elderly Chinese Patients With Fragility Fracture

L. Peng ^*1 , P. She ¹ , J. Yang ¹ , and Z. Luo ²

¹ Orthopedics Department, Xiangya Hospital, ² Xiangya Nursing School, Changsha, China

Introduction: Osteoporosis and fragility fracture have been a more serious health challenge to the elderly worldwide. Inadequate patient knowledge about them can result in various poor clinical outcomes. The purpose of the study was to (1) investigate osteoporosis knowledge among the patients with fragility fractures at an orthopedic ward in mainland China; (2) to evaluate the effectiveness of a nurse-initiated educational intervention on knowledge and awareness. Methods: In total, 51 eligible patients diagnosed with fragility fracture admitted in orthopedic wards in a tertiary hospital in central China were recruited and received a three-session inpatient osteoporosis education program. The intervention consisted of three face-to-face osteoporosis nurse education using easy-to-read educational materials, and the teach-back method, Participants completed questionnaires measuring demographics and osteoporosis knowledge at baseline and at discharge. Data were analyzed using descriptive analysis and compared t test. Results: In our study, 74.5 percent of participates were female and the average age was 63.4 ± 9.5 years. Osteoporosis knowledge increased from baseline to post-intervention in self-made questionnaire and item 1, 3–6, 9–11, 13, 15, 18 and 19 of the OKAT questionnaire (P < 0.05). Conclusion: The three-session inpatient osteoporosis education program was effective at improving osteoporosis knowledge among elderly Chinese inpatients with fragility fracture.

P108: A Retrospective Observational Study of Osteoporosis Management After a Fragility Fracture in Primary Care

A. Bell ^*1 , D. L. Kendler ² , A. A. Khan ³ , M. Shapiro ⁴ , A. Morisset ⁵ , J.-P. Leung ⁶ , M. Reiner ⁷ , S. M. Colgan ⁷ , M. Packalen ⁸ , and L. Slatkovska ⁸

¹ Family and Community Medicine, University of Toronto, Toronto, ² Department of Medicine, Division of Endocrinology, University of British Columbia, Vancouver, ³ Department of Medicine, Divisions of Endocrinology and Metabolism and Geriatrics, McMaster University, Hamilton, ⁴ Department of Family and Community Medicine, University of Toronto, Toronto, ⁵ Department of Medicine, Division of Internal Medicine, Sherbrooke University, Sherbrooke, ⁶ Department of Family Medicine, University of Calgary, Calgary, Canada, ⁷ Amgen Inc., California, USA, ⁸ Amgen Canada Inc., Mississauga, Canada

Introduction: A fragility fracture is a clinical manifestation of osteoporosis and a major risk factor for subsequent fracture in adults aged 50+, yet adherence to secondary prevention strategies is lacking internationally. This retrospective observational study aimed to characterize post-fracture management in the Canadian primary care setting. Methods: A cohort of 778 patients with an index fragility fracture occurring between January 1, 2014 and December 1, 2016 was identified from medical records reviewed at 76 primary care centers in Canada, with follow-up until January 2018. Fragility fracture was defined as a fracture occurring without major trauma at any skeletal site other than the skull, face, cervical spine, hand, metatarsus, phalanges or patella. Patients were excluded if they had a history of fragility fracture in the five years prior to their index fracture. Results: Of all 778 patients identified (80.5% female, median age [IQR] 73 [64–80]), 215 were on osteoporosis treatment and 269 had osteoporosis diagnosis recorded prior to their index fracture. The median follow-up after index fracture was 363 (IQR 91–808) days. Of patients not on osteoporosis treatment at their index fracture, 60.2% (n = 339 of 563) remained untreated after their index fracture and 62.2% (n = 23 of 37) continued untreated after their subsequent fracture. After their index fracture, fracture risk assessment (FRAX or CAROC) was not performed in 83.2% (n = 647 of 778) of patients, and 59.9% (n = 466 of 778) of patients did not receive BMD testing. Of patients with available data who did not have osteoporosis diagnosis recorded prior to their index date, 61.3% (n = 300 of 489) remained undiagnosed over the interval from index fracture to the end of follow-up. At least one subsequent fracture occurred in 11.5% (n = 86 of 778) of patients after their index fracture until the end of study follow-up. Conclusion: In the primary care setting, fragility fracture infrequently resulted in osteoporosis treatment and very infrequently led to fracture risk assessment. Even after experiencing multiple fragility fractures over a relatively short follow-up, the majority of patients remained untreated. These results suggest a fragility fracture is not recognized as a major risk factor for subsequent fracture and its occurrence does not prompt primary care physicians to intervene. These data call forth initiatives to identify and overcome obstacles to primary care physicians’ effective management of patients after fragility fractures.

P109: Atypical Femoral Fractures Due to Long-Term Use of Bisphosphonates in Osteoporotic Patients. A 10-Year Retrospective Study

D. Begkas ^*1 , G. Geogrgiadis ² , S. T. Chatzopoulos ¹ , A. Balanika ³ , and A. Pastroudis ¹

¹ 6th Orthopaedic Department and Osteoporosis Department, ² 4th Orthopaedic Department and Osteoporosis Department, ³ Deparment of Computed Tomography and Department of Osteoporosis, Asclepieion Voulas General Hospital, Athens, Greece

Introduction: Atypical femoral fractures (AFFs) have been associated in the literature with the use of BPs. Long-term use or high dose of BPs inhibit osteoclast function and cause a reduction of bone turnover and alterations of bone structure and biomechanics. Microcracks within the lateral femoral cortex are not adequately repaired due to severe bone suppression, they accumulate and over the time they can cause a fracture. The purpose of this study was to report the clinical and radiological features and to evaluate the results of the surgical treatment of AFFs associated with long-term use of BPs. Methods: During the period 2006–2016, we retrospectively examined 31 patients with a mean age of 71.2 (60–83) years, who were diagnosed with AFFs (N = 34, 3 patients with bilateral fractures) associated with long-term use of BPs. The fractures were selected according to the criteria of the American Society for Bone and Mineral Research. All cases were treated surgically with antegrade intramedullary nailing (AIN). The duration of treatment with BPs, the preoperative and postoperative clinical and radiological findings and the occurrence of complications were evaluated. Results: The average follow-up duration was 32.3 (12–72) months. The mean duration of BPs treatment was 7.2 (4–10) years. Twelve (35.3%) fractures were subtrochanteric and 22 (64.7%) were fractures of the femoral diaphysis. The average fracture healing time was 4.8 (2–9) months. In 8 (23.5%) cases of fractures there was a failure of healing and revision of AIN with a larger diameter nail, resulting in their healing within 4 months postoperatively. Twenty-six patients (76.5%) returned to their preoperative motor and functional status, while 8 (23.5%) patients presented with varying degrees of motor and functional disorders. No other complications occurred. Conclusion: Long-term use of BPs is directly related to the cause of AFFs. Their surgical treatment is demanding and is associated with an increased rate of fracture healing failure and reduced motor and functional capacity of patients postoperatively.

P110: Denusomab Prescription in Hip Fracture Patients in a District General Hospital in England

A. Samat ^*1 , H. Naeem ¹ , H. Brzezicki ¹ , F. Zahir ¹ , and A. Chatterjee ¹

¹ Royal Berkshire Hospital, Reading, UK

Introduction: A Quality Improvement Project (QIP) was undertaken to evaluate the prescription of Denusomab, a RANK ligand inhibitor, for secondary prevention of osteoporosis in hip fracture patients at the Royal Berkshire Hospital in England. The aim was to ensure appropriate patients were selected for Denusomab therapy. Methods: Patients receiving parenteral therapy were identified from the Hospital Pharmacy records and then cross checked with the National Hip Fracture database (NHFD). All hip fracture patients who received Denusomab between February 2019 and February 2020 were included. Clinical data was gathered from electronic patient records. This included patient age, gender, place of residence, gastrointestinal diseases, previous bone protection, estimated glomerular filtration rate (eGFR) and vitamin D level prior to Denusomab referral. Results: 494 hip fracture patients were managed at Royal Berkshire Hospital between February 2019 and February 2020. 23% (116/494) were prescribed parenteral bone protection therapy, of whom 49% (57/116) were prescribed Denusomab. Average age was 84 and 77% (44/57) were female. 93% (53/57) were living in their own home or supported living with 7% (4/57) in residential or nursing homes. 37% (21/57) had experienced a fragility fracture on oral bisphosphonate therapy. 40% (37/57) were known to have upper GI pathology including oesophagitis, gastro-oesophageal reflux, gastritis, hiatus hernia or oesophageal cancer. 98% (56/57) had an eGFR more than or equal to 30ml/min/1.73 m². 79% (45/57) had evidence of significant comorbidity including cognitive impairment or malignancy. 85.9% (49/57) had vitamin D level measured prior to Denosumab infusion. 26.3% (15/57) did not receive a Vitamin D loading dose. 100% had bone profile checked. Conclusion: Secondary fracture prevention forms a key component of hip fracture management, necessitating appropriate prescription of bone protective medication. Decision making requires Orthogeriatric input and consideration of factors including renal function, age, mobility, gastrointestinal diseases and bisphosphonate failure. This QIP demonstrated appropriate selection of patients requiring Denusomab. Vitamin D levels should be checked and replaced before infusion to avoid hypocalcaemia. As this is a new service within the Hip Fracture Unit, a rolling teaching programme has been launched to educate staff about osteoporosis and safe delivery of parenteral therapy.

P111: Cost-Effectiveness Assessment of Fracture Liaison Service for Secondary Prevention of Fragility Fractures in the Spanish Setting

A. Naranjo ^*1 , D. Prieto-Alhambra ² , J. Sánchez-Martín ³ , A. Pérez-Mitru ³ , and M. Brosa ³

¹ Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Barranco de La Ballena s/n, 35011, Las Palmas de Gran Canaria, Spain, ² NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Oxford, UK, ³ Oblikue Consulting, Barcelona, Spain

Introduction: The objective of Fracture Liaison Service (FLS) is to reduce the risk of subsequent fractures by systematically identifying and treating patients who have suffered a fragility fracture. There are numerous cost-effectiveness publications of different FLS models but there is a lack of published health economics assessments of FLS in the Spanish setting. This study aims to assess the cost-effectiveness of FLS compared to standard of care for secondary prevention of fragility fractures in Spain. Methods: A cohort of osteoporotic (OP) patients after initial fragility fracture who were candidates to initiate anti-OP treatment with a mean age of 65 years old and a mean proportion of females of 90.7% was included in the model. Disease was modelled with a Markov model through 7 health states (with and without anti-OP treatment, subsequent hip, vertebral, forearm and humerus fracture, and death). A time horizon of 10 years and a 6-month duration per cycle was set. Clinical, economic, and quality of life parameters were drawn from the literature and local practice. Use of resources and treatment patterns were validated by a panel of experts. The National Health System [NHS] perspective was adopted, considering direct healthcare costs expressed in 2020 Euros. A discount rate of 3% was applied to costs and healthcare outcomes. Uncertainty of the parameters was assessed through deterministic, scenario and probabilistic sensitivity analyses. Results: Setting up a FLS for the secondary prevention of fragility fractures in Spain would provide a greater anti-OP treatment initiation and persistence. This would reduce subsequent fragility fractures, which would result in a reduction of disutilities and deaths. The results of this analysis showed a greater clinical benefit (0.01 and 0.08 life-years and quality-adjusted life years [QALYs] gained per patient, respectively) and a higher cost (€563.69 per patient) compared to standard of care, leading to an incremental cost-utility ratio of €6,855.23 per QALY gained. The sensitivity analyses showed limited dispersion of the base case results, corroborating their robustness and conservative approach. Conclusion: From the NHS perspective and considering the local willingness-to-pay thresholds, the implementation of FLS would be cost-effective in the Spanish setting compared to standard care for secondary prevention of fragility fractures.

P112: Staff Education and Training for Pareneteral Osteoporosis Therapy in the Hip Fracture Unit

H. Naeem ^*1 , F. Zahir ¹ , A. Samat ¹ , H. Brzezicki ¹ , and A. Chatterjee ¹

¹ Elderly care, Royal Berkshire Hospital, Reading, UK

Introduction: Parenteral therapy (Zolendronic acid and Denosumab) for the management of osteoporosis in Hip fracture patients was traditionally done at the Infusion unit at the Royal Berkshire Hospital, Reading, UK. From July 2020 parenteral therapy has been commenced on the specialist Hip Fracture thereby reducing the waiting period for the first dose. Staff were educated and a survey was conducted five months later. Methods: A staff survey was conducted over a three-month period from November 2020 to January 2021 to ascertain their knowledge about parenteral therapy in osteoporosis. All staff members directly involved in parenteral infusion were included, i.e., doctors, nurses, physician associates and pharmacists. A questionnaire was designed; data was collected and analysed on Excel sheet. Results: 36 participants took part in the survey, 58% (21/36) were nurses and 33% (12/36) were doctors. Data was split into two groups, based on similarity in roles and knowledge. First group included 21 nurses of which 62% (13/21) were band 5. 90% (19/21) nurses reported their knowledge of osteoporosis was adequate or good whilst 52% (11/21) reported awareness of parenteral drug therapy for osteoporosis. 70% (15/21) were not conversant with safety precautions required prior to and during parenteral infusion. Only 2 nurses mentioned hypocalcaemia as a potential side effect. 85% (18/21) showed interest in attending further training on parenteral therapy. Second group included 12 doctors, 2 pharmacists and 1 physician associate. 80% (12/15) reported their knowledge of osteoporosis to be adequate or good. 80% (12/15) reported awareness of parenteral therapy for osteoporosis. 46% (7/15) were not aware of safety parameters and 73% (11/15) mentioned hypocalcaemia as a potential side effect. All participants were keen to attend teaching sessions on parenteral therapy. Conclusion: It was observed that staff had adequate knowledge of osteoporosis but the nurses lacked insight of specialist knowledge on parenteral therapy for osteoporosis, safety precautions pre- and post-infusion. We have introduced rolling teaching sessions for parenteral therapy in osteoporosis for nurses and doctors. Sessions covered osteoporosis, parenteral therapy including indications, vitamin D loading, consenting, and safety precautions with pre- and post-infusion monitoring. Staff have welcomed this initiative and given positive feedback. We have also introduced a POSTER for guidance.

P113: Zolendronic Acid Prescriptions in Hip Fracture Patients in a District General Hospital in England

H. Brzezicki ^*1 , A. Chatterjee ¹ , H. Naeem ¹ , A. Samat ¹ , and F. Zahir ¹

¹ Royal Berkshire Hospital, Reading, UK

Introduction: A Quality Improvement Project (QIP) was undertaken to evaluate the prescription of Zolendronic Acid, a parenteral bisphosphonate, in the secondary prevention of osteoporosis in hip fracture patients at the Royal Berkshire Hospital (RBH) in England. The aim was to ensure appropriate patients were selected for Zolendronic Acid therapy. Methods: Patients receiving parenteral therapy were identified from the Hospital Pharmacy records and then cross checked with the National Hip Fracture database (NHFD). All hip fracture patients who received Zolendronic Acid between February 2019 and February 2020 were included. Clinical data was gathered from electronic patient records. This included patient age, gender, place of residence, gastrointestinal (GI) disease, estimated glomerular filtration rate (eGFR) and vitamin D level prior to Zolendronic Acid infusion. Results: 494 hip fracture patients were managed at RBH between February 2019 and February 2020. 23% (116/494) were prescribed parenteral bone protection therapy, of whom 51% (59/116) were prescribed Zolendronic Acid. 63% (37/59) were 90 or over and 68% (40/59) were female. 66% (39/59) were living in their own home or supported living whilst 34% (20/59) in residential or nursing homes. 36% (21/59) were known to have upper GI pathology including oesophagitis, gastritis, gastro-oesophageal reflux, hiatus hernia, dysphagia, prior perforated peptic ulcer and alcohol dependence. 100% (59/59) had an eGFR of more than or equal to 30mL/min/1.73 m². 90% (53/59) had evidence of significant comorbidity including cognitive impairment or malignancy. 98% (58/59) had a vitamin D level measured prior to Zolendronic Acid infusion. 100% had their bone profile checked. Conclusion: In an ageing population, the choice of bone protection for secondary fracture prevention is increasingly complex and requires a patient-centred approach with orthogeriatric input. A once yearly Zolendronic Acid infusion is appropriate for frail, older patients particularly aged 90 or over with multiple comorbidity including dementia, or patients with gastrointestinal disease. This QIP showed patients were appropriately referred for Zolendronic Acid. The risk of hypocalcaemia necessitates Vitamin D replacement prior to infusion and the measurement of calcium levels post-infusion. A new teaching programme on the Hip Fracture Unit focusing on the indications, contraindications and side effects of Zolendronic Acid will improve patient safety in the consent and referral process.

P114: The Fragility Hip Fracture: Not Only a Marked Burden of Disease, but Also a Significant Predictor of Subsequent Hip Fracture Risk

E. Schemitsch ^*1 , J. D. Adachi ² , J. P. Brown ³ , J.-E. Tarride ⁴ , N. Burke ⁵ , T. Oliveira ⁵ , and L. Slatkovska ⁵

¹ Division of Orthopaedics, Department of Surgery, Western University, London, ² St Joseph's Healthcare, McMaster University, Hamilton, ³ CHU de Quebec (CHUL) Research Centre, Laval University, Quebec City, ⁴ Department of Health Research Methods, Evidence and Impact (HEI), McMaster University, Hamilton, ⁵ Amgen Canada Inc., Mississauga, Canada

Introduction: Hip fracture is one of the most common fragility fractures caused by osteoporosis. We describe the contribution of hip fractures to fragility fracture burden in elderly adults in Ontario, Canada. Methods: This retrospective observational study used de-identified health services data generated from the publicly funded healthcare system in Ontario, Canada. The cohort included men and women aged >65 years with an index fragility fracture between January 1, 2011 and March 31, 2015, identified using ICD-10 codes from hospital admissions, emergency and ambulatory care. Patients were followed to a cutoff date of March 31, 2017. Results: The cohort consisted of 115,776 patients with an index fragility fracture. The median age (interquartile range) was 81 (74–87) years and 72.3% were female. Hip fracture was the most common index fracture (27.3%, n = 31,613), and 32.4% (n = 10,254) of index hip fractures occurred in patients ≤80 years of age. Proportion of index fractures that were hip fractures by age was: ages 66–70, 12.1% (n = 2,179); ages 71–75, 17.3% (n = 3,092); ages 76–80, 24.2% (n = 4,983); ages 81–86, 31.2% (n = 7,524); and ages 86+, 39.3% (n = 13,835). Hip fracture was also the most common second fracture (27.8%, n = 5,745). It occurred as the second fracture in ≥19% of cases for all index fracture sites examined; occurring most often after hip (33.0%) or pelvic (32.3%) index fractures, and least often after tibia/fibula/knee (23.3%) or radius/ulna (19.4%) index fractures. Among patients requiring surgery related to their index fracture (n = 44,949) and those experiencing complications 30 days post-surgery (n = 8,868), respectively, 64.1% and 71.9% had a hip fracture. One-year mortality (due to any cause) was 26.2% after hip index fracture and 15.9% in the entire cohort; hip fracture had the highest mortality rate of all index fracture sites examined, followed by femur (21.9%). Total mean (± standard deviation) healthcare cost per patient (in 2017 Canadian dollars) in the first year after index fracture was the second highest for hip index fracture ($62,793 ± 44,438), after femur index fracture ($65,490 ± 54,116). Conclusion: These data highlight the significant morbidity, mortality and financial burden of hip fragility fractures in adults aged >65 and the urgent need to initiate secondary fracture prevention measures after a fragility fracture occurring at any site to help reduce subsequent hip fracture and associated burden.

P115: Successful Integration of a Fracture Liaison Service Within an Orthopaedic Fracture Clinic

S. Narula ^*1 , L. Welthy ² , D. Kelly ¹ , A. Mattin ¹ , and H. Seymour ²

¹ Orthopaedic Surgery,, ² Geriatric Medicine, Fiona Stanley Hospital, Perth, Australia

Introduction: Its estimated in 2022 that 6.2 million Australians will be living with osteopaenia or osteoporosis, they will suffer 183,105 fractures in that year which will cost the health care system 3.84 billion dollars. Treating osteoporosis reduces the risk of future fracture by 50% yet on average only 20% of patients who come to medical attention with an osteoporotic fracture are appropriately investigated and treated. Methods: We established a pathway within the existing orthopaedic outpatient clinic structure to identify patients with potential fragility fractures, perform appropriate investigations and where suitable commence therapy. Patients were provided with further education on osteoporosis, the investigations and potential treatment. Results: In women over the age of 50 with upper limb fragility fractures, 30% were investigated and or commenced on treatment for osteoporosis compared to 15% in the 6 months prior to the OOPS roll out. We also observed an increase in the percentage of patients who were already on treatment from 26% to 47%. There were still 161 patients who would have benefited from investigation and or treatment during the audit period. Conclusion: The identification, investigation and treatment of osteoporosis among patients with a fragility fracture is proven to reduce the burden and morbidity of further fractures. We have developed a system that can be integrated into our current models of care that leads to improvement in the number of patients investigated and or commenced on therapy for osteoporosis. Health Services across the state should consider implementing similar pathways.

P116: Orthopedic Fracture Liaison Service for Osteoporosis Fractures: Is It Working?

O. Or ^*1 , T. Fisher Negev ¹ , H. Vered ¹ , R. Shabtai ¹ , A. Katzir ¹ , Y. Weil ¹ , and M. Liebergall ¹

¹ Hadassah Medical Center, Hadassah Medical Center, Jerusalem, Israel

Introduction: Osteoporosis is a common disease of the older age. A devastating result of osteoporosis is a hip fracture with up to 30% mortality rate in one year. The compliance rate of osteoporotic medication following a hip fracture is 20% in the western world. We evaluate the impact of FLS in the orthopedic department on patient’s compliance to osteoporosis medication following hip fracture. Methods: Retrospective review of all patients with hip fracture who were involved with the fracture liaison service. We collected data regarding kidney function, calcium levels, parathyroid hormone levels and vitamin D levels at admission. We educated the patient and family while admitted, started vitamin D and calcium supplementation and recommended on osteoporotic medical treatment. We contacted the patient 6–12 weeks following the fracture by phone call to ensure treatment initiation. Results: From 6/2018 to 06/2019, we identified 166 patients with hip fracture who completed at least one year of follow up. Over 75% of the patients had low vitamin D levels and 22% had low calcium levels at admission. 9 patients (5%) died at median of 109 days. Following our intervention, 161 (96%) patients were discharged with a specific osteoporotic treatment recommendation. 121 (73%) patients received medication for osteoporosis on average of less than 3 months from surgery. We recommended on injectable medications, however, 51 (42%) were treated with oral bisphosphonate. Conclusion: fracture liaison service in the orthopedic department has improved the compliance rate to osteoporotic medical treatment and may decrease mortality. It should be a clinical routine in every medical center.

P117: Opportunistic Identification of Vertebral Compression Fractures Using Artificial Intelligence Technology

C. Gunasingam ^*1 , A. Jaunalksnis ² , L. Koller-Smith ³ , S. Beautement ² , V. Chan ² , and G. Major ^1,4

¹ Rheumatology, The Royal Newcastle Centre, Newcastle, NSW, ² Hunter New England Imaging Service, ³ Rheumatology, The Royal Newcastle Centre,, ⁴ The University of Newcastle, Newcastle, NSW, Australia

Introduction: Vertebral fractures are a powerful predictor of further fractures and are associated with significant morbidity and mortality. The majority do not come to medical attention and are underreported by radiologists. The Zebra Medical Vision Ltd. compression fracture detection algorithm can be applied to any computed tomography (CT) scan of the chest or abdomen. The aim was to evaluate the utility of the algorithm in the identification of vertebral fractures in patients having chest and/or abdomen CT scans performed for any reason at a tertiary referral hospital. Methods: CT examinations of patients aged ≥50 years (104 abdominal; 103 chest) requested in the course of their management were evaluated. Acquisition was of consecutive studies over a two-week period. The Zebra algorithm was applied retrospectively to digitised data. A manual search of the reports of these scans was undertaken to assess if a fracture had been noted, as well as an automated search using Report Analytics software. Applying standardised criteria for the classification of vertebral fractures, scans were also assessed by an expert radiologist blind to the report and algorithm findings. The clinical utility of the Zebra tool was explored 12 months post initial analysis, through review of the medical records of patients flagged positive for vertebral fracture by the Zebra algorithm. Results: The prevalence of vertebral fractures by expert radiology opinion was 16.5%. The sensitivity of the Zebra algorithm was 58.8% with specificity 94.2%, positive predictive value 66.7% and negative predictive value 92.1%. The sensitivity of routine reporting was low at 38.2%. Report Analytics identified 11 of 14 documented vertebral fractures. Of the 20 films identified as positive on Zebra analysis where there were true vertebral fractures, 19 of these were deemed osteoporotic in nature. 12 of these patients did not have a prior diagnosis of osteoporosis. 8 of these 12 patients survived at four months, 1 of which had a documented re-fracture. Conclusion: The Zebra algorithm showed high specificity and compared to routine reporting, higher sensitivity. It offers an advance in the opportunistic detection of prevalent vertebral fractures.

P118: Multidisciplinary Approach to Reduce Postoperative Complications and Reduce Contralateral Hip Fracture

N. Imai ^*1 , O. Muraoka ² , T. Kuraishi ² , T. Fukuhara ² , M. Imai ² , and T. Yoshimine ²

¹ Div. of Comprehensive Musculoskeletal Medicine, Niigata Univ, Niigata, ² Niigata Prefectural Tokamachi Hospital, Tokamachi, Japan

Introduction: Multidisciplinary approaches such as fracture liaison services (FLS) have been reported to reduce medical complications and secondary fractures in patients with fragility hip fracture and in our institution, FLS similar to the previous study was introduce from 2018. The purpose was to investigate the outcomes of the patients with fragility hip fracture following the introduction of FLS. Methods: Patients >50 years old suffered from fragility hip fractures between June 1, 2017 and June 30, 2020 were enrolled, and divided as a control group (without FLS; 138 patients) and FLS group (209 patients). Results: We found that the time from injury to surgery decreased significantly from 2.50 to 1.84 days (P < 0.01), and the number of cases with complications, total cases, pulmonary disease, urological disease, and delirium after admission decreased significantly (P < 0.01) in the FLS group. Hospital stay was decrease 48.3 to 42.3 days (P < 0.05). The rate of osteoporosis medication was increase 18.8% to 71.2% at the time of their discharge, 29.4% to 83.6% at 6 months after discharge, 39.4% to 86.3% at 12 months after discharge, and 36.2% to 85.1% at 24 months after discharge. The mortality rate was decreased 1.4% to 0.5% within 1 month, 12.3% to 6.2% within 12 months, and 17.4% to 9.1% within 24 months from their first hip fracture. The rate of contralateral hip fracture was also decreased 2.9% to 1.4% within 12 months, and 5.8% to 2.4% within 24 months from their first hip fracture. Conclusion: Our FLS contributed to decrease complications after admission, hospital stay, secondary hip fracture rate, and mortality rate.

P119: High Adherence to Secondary Prevention Treatments, Low Re-Hospitalization and Mortality Rates Among Older Adults With Hip Fractures Entered the Orthogeriatric Outpatient Service

M. Baroni ^*1 , A. R. Bianco ¹ , M. Ferracci ¹ , G. R. Talesa ² , A. Cirimbilli ² , V. Prenni ¹ , V. Bubba ¹ , V. Boccardi ¹ , G. Rinonapoli ² , A. Caraffa ² , P. Mecocci ¹ , and C. Ruggiero ¹

¹ Geriatric and Orthogeriatric Unit, SM Misericordia Hospital, University of Perugia, Italy, ² Orthopedic and Traumatologic Unit, SM Misericordia Hospital, University of Perugia, Italy, Perugia, Italy

Introduction: To compare the outcomes of hip fracture patients who entered the interdisciplinary fracture liaison services (FLS) with those who followed the usual orthopedic care (UOC). Methods: A prospective observational study including subjects aged ≥65 years hospitalized because of hip fracture. At the time of discharge, participants who underwent surgery were invited to enter FLS, received schedule of laboratory and x-ray exams and outpatient orthogeriatric assessment within 30 day from surgery. Results: Among 762 patients eligible within 1 year, 540 (71.0%) attended the 30-day outpatient visit: 268 (49.6%) opted for FLS while 272 (50.3%) for UOC. The patients who entered the FLS compared to those in the UOC had higher 1-year adherence to Vitamin D supplementation, plus calcium if needed, as well as adherence to specific anti-osteoporosis drug (75.1% vs 8.0%; P < 0.0001), and complete anti-fracture treatments (defined as combination of specific anti-osteoporosis drug plus vitamin D, and calcium if needed) (72.3% vs 5.7%; P < 0.0001). The older adults who entered the FLS experienced a longer time of hospitalization free survival (176.4 vs 88.7 days; P = 0.0152) compared to those in UOC. Compared with participants in the UOC, a tendency to a lower annual mortality rate (19.7/100 person-year vs 25.5/100 person-years; HR = 0.62; 95% CI 0.35; 1.09) was found in those entered the FLS group independent of confounders. Conclusion: The FLS may increase initiation and adherence to antifracture treatments over time. Compared with UOC, FLS may positively impact on health-related outcomes, such as time free from re-hospitalization and mortality rates.

P120: Discharge Summary Documentation Post Hip Fracture Can Increase Osteoporosis Treatment

J. Perring ^*1 , H. Seymour ¹ , L. Welthy ¹ , and M. Pindolia ¹

¹ Fiona Stanley Hospital, Perth, Australia

Introduction: Hip fractures contribute to significant morbidity and mortality in older people, making prevention a priority. Routine prescription of osteoporosis treatment at discharge from a hip fracture increases rates of secondary prevention. However, the uptake of therapy following discharge in a metropolitan Australian setting is unknown. This study aims to address the in-hospital and discharge factors affecting uptake by implementing a quality improvement project. Methods: A retrospective review of hip fracture cases treated at Fiona Stanley Hospital within July and August 2020 was performed. These patients were intended to have osteoporosis treatment prescribed on discharge. They were then followed up after a three month interval to establish if treatment had been commenced. Patients’ discharge summaries were analysed for inclusion of optimal information: osteoporosis diagnosis, discharge plan, listing of osteoporosis medication, and information to General Practitioner (GP). Statistical analysis was then performed to evaluate impact of documentation on osteoporosis treatment uptake, and provide recommendations for quality improvement. Results: A total of 89 patients with hip fractures were identified. 17 patients passed away prior to follow-up and thus were excluded. 68% of the 65 patients who were advised to commence Denosumab received at least one dose following discharge. One of the two patients who were recommended Risedronate commenced therapy at discharge. Discharge documentation was inconsistent between cases. 51% of summaries included osteoporosis as a diagnosis, 47% listed osteoporosis therapy in their medication list, 65% included a discharge plan for therapy, and only 25% included this plan in the information to GP section. Inclusion of Denosumab in the medication list resulted in an 10% higher uptake of therapy (73% compared to 63%), but was only included in 45% of summaries. Inclusion of a specific discharge plan for Denosumab contributed to a 14% increase in uptake (72% compared to 58%), but this was only done for 65% of summaries. Repeat analysis of uptake following quality improvement based on these findings will be completed in 2021. Conclusion: Current rates of commencement of osteoporosis therapy can be improved. Sufficient discharge documentation contributes to higher rates of treatment for osteoporosis in the community following hip fracture. Thus standardisation of optimal discharge information is recommended to further improve osteoporosis treatment rates.

P121: Perspectives of Patients With Depression and Chronic Pain About Bone Health After a Fragility Fracture

J. Sale ^*1,2 , M. Gignac ³ , L. Frankel ¹ , S. Thielke ⁴ , E. Bogoch ¹ , V. Elliot-Gibson ¹ , G. Hawker ² , and L. Funnell ⁵

¹ Unity Health Toronto, ² University of Toronto, ³ Institute for Work & Health, Toronto, Canada, ⁴ Puget Sound VA Medical Center, Seattle, USA, ⁵ Osteoporosis Canada, Toronto, Canada

Introduction: Compromised bone health is often associated with depression and chronic pain. Our objectives were to examine: (1) the experience of existing depression and chronic non-fracture pain in patients with a fragility fracture; and (2) the effects of the fracture on depression and pain. Methods: We conducted a phenomenological study guided by Giorgi’s analytical procedures. Participants were fracture patients recruited through a Fracture Liaison Service who reported taking prescription medication for one or more comorbidities, excluding compromised bone health. Patients were interviewed within six weeks of their fracture, and one year later. Interview questions addressed the recent fracture and patients’ experience with bone health and their other health conditions, such as depression and chronic pain, including the medications taken for these conditions. Results: Twenty-six patients (5 men, 21 women) aged 45–84 years old with hip (n = 5) and non-hip (n = 21) fractures were recruited. Twenty-one participants reported depression and/or chronic non-fracture pain, of which seven reported having both depression and chronic pain. Two themes were consistent based on our analysis: (1) depression and chronic pain overshadowed attention to bone health; and (2) the fracture exacerbated reported experiences of existing depression and chronic pain. Conclusion: Experiences with depression and pain take priority over bone health and may worsen as a result of the fracture. Health care providers treating fragility fractures might ask patients about depression and pain and take appropriate steps to address patients’ more general emotional and physical state.

P122: Implementing the First Fracture Liaison Service in Chile: Early Results

S. Leyan ^*1 , I. Klaber ¹ , C. Vidal ¹ , G. Gonzalez ² , and D. Schweitzer ¹

¹ Orthopaedics, ² Endocrinology, Pontific Catholic University of Chile, Santiago, Chile

Introduction: Every year about 9 million fragility fractures occur worldwide. 80% of these fragility fractures are undiagnosed or untreated. In order to close the gap of diagnosis and treatment of osteoporosis, Fracture Liaison Services (FLS) were created. Currently there are no clinical guidelines, protocols or FLS in Chile for diagnosing or treating fragility fractures. Objective: To describe the implementation of the first FLS in Chile, its inclusion criteria, patient enrolment, referrals to other healthcare members and treatment adherence during the first year. Methods: This FLS operation was based in a university affiliated health care network compound by 2 hospitals. The Best Practice Framework guidelines of the International Osteoporosis Foundation campaign “Capture the Fracture” (CTF) were applied. A nurse practitioner worked as coordinator for the program. From May 2020 to April 2021 all the patients diagnosed with a fragility fracture in the emergency rooms were contacted and invited to participate. Demographical data, anatomical site of the fracture, previous fractures, treatment prescribed and adherence, and mortality were all recorded. Patients with pathological fractures and active cancer were excluded from the FLS. Results: During the first year of this FLS, 443 patients were diagnosed with fragility fractures and met the inclusion criteria, 177 patients (40%) accepted to participate in the program. The average age of the participants was 73.8±13.3 years and 84% were female. Hip fractures were more frequent (67/177). Of the 177 patients, 95 reported previous fragility fractures, 32 had osteoporosis diagnosed, 20 patients reported past or current treatment for osteoporosis. At the 4-month follow-up 62% had received vitamin D/calcium supplementation and 50% of the patients with prescription for antiosteoporotic drugs had received them. Secondary referral to Endocrinology was required in 28% of the cases due to secondary osteoporosis or subsequent fractures occurred while under antiosteoporotic treatment. After 6 months of operation the FLS was listed as a recognized FLS by CTF. Conclusion: During the first year of operation of this FLS 40% of the candidates were enrolled and half of the participants had received anti osteorotic treatment 4 months after their fracture. The FLS was able to manage 72% of the patients without the need of secondary referrals. There is still much work to do closing the gap of treatment in Chile and developing local guidelines.

P123: Previous Fractures and Subsequent Fractures After Proximal Humeral Fracture in Elderly Patients

A. Kanno ^*1,2 , and T. Aizawa ²

¹ Orthopaedics, Sendai South Hospital, Sendai, ² Orthopaedics, Iwaki Medical Center, Iwaki, Japan

Introduction: Osteoporosis is main reason of proximal humeral fracture (PHF) in elderly people. Subsequent fracture risk after fragile fracture is high. However, there are seldom reports about subsequent fragile fracture and/or osteoporosis after PHF. The aim of this study is to investigate previous fracture, subsequent fracture, and osteoporosis treatment after PHF in elderly patients. Methods: The subjects are the 136 patients (24 men and 112 women) who sustained PHF by fall from standing position, between April 2016 and March 2019. All patients’ treatments were undergone at Iwaki Medical Center. Average age at injury was 76.4 (50 to 102). Exclusion criteria were as follows: patients with high energy injury, those who had been referred to other clinic within 1 month after injury, the patients under 50-year-old. Medical history of previous fragile fracture, occurrence of simultaneous fracture and subsequent fracture were investigated. Osteoporosis treatment was also investigated. Results: 23 patients had history of previous fragile fracture. Among these patients, 14 patients had suffered proximal femoral fracture (PFF) or spine fracture. 6 patients suffered other fracture simultaneously with PHF. 16 subsequent fractures occurred after PHF in 15 patients: among these patients, 6 had PFF, 3 had contralateral PHF, 2 had periprosthetic fracture of ipsilateral humerus. 21 patients had taken osteoporosis drug before PHF. Other than these patients, 29 patients started osteoporosis treatment after PHF. Among these patients, teripartide was used in 23 patients: this treatment was interpreted after callus formation or bone union in 20 patients. In these patients, other osteoporosis treatment was not confirmed. Conclusion: Previous fracture and subsequent fracture was common in patients with PHF. In most patients, osteoporosis treatment is not performed: otherwise, the period of treatment was too short. Osteoporosis examination, diagnosis, and treatment was necessary in elderly patients with PHF.

P124: Are Psychotropic Drugs and/or Polypharmacy Associated With Hip Fracture Severity, Hypovitaminosis D and Secondary Hyperparathyroidism in Elderly Patients?

I. Papaioannou ^*1 , G. Pantazidou ² , T. Repantis ¹ , A. Baikousis ¹ , and P. Korovessis ¹

¹ Orthopaedic, General Hospital of Patras, ² Public Health MSc, University of Patras, Patras, Greece

Introduction: Polypharmacy and the use of psychotropic agents are established risk factors for falls and hip fractures. This retrospective study evaluates the impact of these factors to the parathyroid hormone (PTH) and 25-hydroxy vitamin D (VD) blood levels and also the fracture severity. Methods: We retrospectively evaluated 76 elderly patients with hip fracture. PTH and VD blood levels were measured. Polypharmacy was defined if a single patient received 4 or more drugs, while we included typical and atypical antipsychotics, tricyclics anti-depressants, selective serotonin reuptake inhibitors and benzodiazepines in the group with psychotropic drugs uptake. We defined the severe sub-capital fractures those with grade 3 or 4 according to Garden classification, while severe intertrochanteric fractures were defined those with grade A2.2, A2.3 and all A3 fractures according to AO/OTA classification. Results: Mean age was 83.08 ± 7,203, male were 28 (36.8%) with mean age 83.71 ± 7.507 and female were 48 (63.2%) with mean age 82.71 ± 7,074. 63.2% (48/76) sustained an extra-capsular fractures, while 36.8% (28/76) had an intra-capsular fracture. Based on our records 39 out of 76 patients (51.3%) received psychotropic drugs. Among them, 26 subjects were female and 13 were male. Polypharmacy was identified in 77.6% of the patients (59/76) and among them 37 were females and 22 males. Only 22.4% of the patients (17/76) received 3 or less drugs per day. In 59 cases associated with polypharmacy we found out 46 cases (77.9%) with comminuted fractures and 13 subjects (22.1) with stable fracture pattern, while in 17 cases without polypharmacy the incidence of the unstable fractures was 64.7% (11/17). Mean VD levels were 10.35 ng/ml and PTH levels were 73.77 pg/ml in cases with psychotropic drugs uptake, while the values of their counterparts were 11.75 ng/ml and 54.11 pg/ml, respectively. Finally, mean VD levels were 9.27 ng/ml and PTH levels were 65.61 pg/ml in cases associated with polypharmacy, while the values of their counterparts were 11.56 ng/ml and 59.29 pg/ml respectively. Conclusion: Clinicians should be aware that both polypharmacy and psychotropic drugs uptake are associated with more unstable hip fractures. In addition, it is also worth-noting that that both polypharmacy and psychotropic drugs uptake are also associated with more severe VD deficiency and increased levels of PTH. Probably, VD deficiency and secondary hyperparathyroidism consist of adverse effects of polypharmacy and psychotropic drugs uptake. 

P125: A New Suggestion to Reduce Atypical Femoral Fractures Associated With Bisphosphonates Uptake

I. Papaioannou ^*1 , G. Pantazidou ² , T. Repantis ¹ , A. Baikousis ¹ , and P. Korovessis ¹

¹ Orthopaedic, General Hospital of Patras, ² Public Health MSc, University of Patras, Patras, Greece

Introduction: Atypical femur fracture (AFF), which is a rare type of fracture that has been associated with the long term use of potent antiresorptive bone medications, is a potentially devastating consequence of osteoporosis treatment. AFF pathogenesis is associated with mechanical and biological mechanisms of cortical bone. This study highlights the patient group that is at high risk for development of this complication from the biomechanical point of view. Methods: We retrospectively studied cases with atypical femoral fractures in the last five years. We retrieved 7 cases, 5 female and 2 male patients. 4 out of 7 patients had diaphyseal AFF, while the rest had sub trochanteric AFF. All of them were treated with alendronate for osteoporosis. Mean age of these patients was 69.7 years old. We examined the radiographs and evaluated the diaphyseal lateral femoral bowing angle and femoral neck shaft angle to clarify if increased femoral lateral bowing (> 5.25 degrees) or decreased femoral neck shaft angle (< 125 degrees), are associated with increased risk for diaphyseal and subtrochanteric AFFs respectively. Results: All patients with diaphyseal AFFs had increased lateral femoral bowing angle and subsequently all patients with sub trochanteric AFFs had decreased neck shaft angle. Mean lateral femoral bowing was 12,9 degrees (SD = 5.5 ), while mean neck shaft angle was 120,3 degrees (SD = 1.24). It is worth noting that in two cases with excessive lateral femoral bowing (> 15 degrees), surgical procedure was very challenging due to the standard design of the intramedullary nail. Conclusion: Based on current evidence and our results about AFFs, we conclude that both femoral bowing angle and femoral neck shaft angle should be evaluated before bisphosphonates (BPs) administration. Ιn cases with excessive lateral femoral shaft bowing or decreased femoral neck shaft angle, prescription of another anti osteoporotic treatment should be recommended. If, however, BPs cannot be avoided, clinicians should be aware of the fact that long term administration may be implicated with AFFs occurrence. Short term BPs administration with timely drug holiday between three and five years may be reasonable. Roentgen graphic evaluation of both femurs every six months and medical reference in case of any emerging thigh pain can prevent AFFs. Larger studies are urgently needed to confirm or contradict this statement.

P126: Asia Pacific Fragility Fracture Alliance Primary Care Toolkit: Empowering Fragility Fracture Education

Y. Choi ¹ , K. Bruce ² , D.-C. D. Chan ³ , J. Close ⁴ , M. Kheradi ² , J. K. Lee ⁵ , L. Mercado-Asis ⁶ , P. Mitchell ⁷ , and R. Blank ^*8

¹ Evidencia Medical Communications Pty Ltd, ² VIVA! Communications Pty Ltd, Sydney, Australia, ³ Superintendent Office, National University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan, Province of China, ⁴ Prince of Wales Hospital, Sydney, Australia, ⁵ Beacon Hospital, Petaling Jaya, Malaysia, ⁶ University of Philippines, Manila, Philippines, ⁷ Synthesis Medical NZ Limited, Auckland, New Zealand, ⁸ The Garvan Institute of Medical Research, Sydney, Australia

Introduction: The Asia Pacific Fragility Fracture Alliance (APFFA) is a federation committed to reducing the burden of low trauma fracture throughout the region. Education on fracture prevention to those at the forefront of patient care is an important part of this effort. Methods: APFFA has curated educational materials developed by others (https://apfracturealliance.org/education-directory/) and developed a Primary Care Physician (PCP) Education Toolkit (https://apfracturealliance.org/education-toolkit/). Here we describe the toolkit and report its introduction during the COVID-19 pandemic. Results: The PCP Education Toolkit is designed as a half-day educational program together with supporting resources to highlight the role of primary care providers in this effort. The educational program includes a lecture focused on the burden of fracture, a lecture focused on clinical assessment of fracture risk, a discussion kit, and materials to assist with meeting planning. The discussion kit is designed to be adaptable to local practices and constraints. The supporting material features a patient handbook that gives practical advice on nutrition, home safety, and issues to be raised during medical encounters. COVID-19 hampered rollout of these materials. In addition, APFFA has relied on its constituent organizations to provide educational content to promote best practices in acute fracture management, rehabilitation, and secondary fracture prevention through the development of an education directory. The directory includes synopses and links to high quality materials from around the world. Conclusion: The PCP Education Toolkit was designed with the expectation that the program would be presented as live meetings. The pandemic made this infeasible. Despite the restrictions, the PCP Education Toolkit materials have been enthusiastically received in New Zealand and disseminated by Osteoporosis NZ. As the world emerges from the pandemic, we are looking to present this material in more venues in 2022 and beyond. The toolkit is available free of charge at the above address.

P127: Concept Adaptation and Pilot Application of an Interdisciplinary Intervention for the Prevention of Falls in Community-Dwelling Older Adults During COVID-19 Pandemic

M. Mentis ^*1 , K. Athanasopoulou ¹ , K. Stolakis ¹ , G. Dimakou ² , I. Marlafeka ³ , C. Koutsouri ³ , E. Giannakou ¹ , and E. Panagiotopoulos ¹

¹ UNIVERSITY OF PATRAS, PATRAS, ² 251 Air Force General Hospital, ATHENS, ³ General Hospital of Eastern Achaia, AIGIO, Greece

Introduction: Falls are a major health problem in older adults, leading to serious injuries and burdening their quality of life and functionality. Social isolation is predictive of falls, so a need for effective distance interventions is of great importance in this vulnerable population. Methods: An interdisciplinary programme for falls prevention was designed in community-dwelling older adults at falls risk, including physical exercise, nutritional education and falls prevention training. Screening measurements took place before and after the intervention for a complete assessment of the participants’ physical, mental and social state. The implementation of the programme coincided with the lockdown due to the COVID-19 pandemic and this led us to a forceful transformation to a pilot digital programme. Thus, the new version of the programme had driven us to minimize face-to face contact and at the same time ensure that the participants’ healthcare and social support needs were addressed. Moreover, new engagement techniques had to be used. Therefore, a digital platform was created and hosted by the FFN Greece website and 6 zoom teleconferences were organized with health professionals (orthopaedic, social worker, geriatrician, nutritionist). In addition, the participants could communicate with a psychologist and had zoom dancing lessons once a week. The digital educational material was adapted in order to provide the participants with health information regarding copying with falls incidents during the pandemic home restriction. Results: 20 people participated in the programme (95% women, mean age: 69 years). Among the most important results of the intervention were: The reduction of Fear of Falls (FES-I mean score before and after the intervention 28.1 vs 26.3, respectively); The improvement of important aspects of quality of life (SF-36 Physical Functioning mean score and SF-36 Emotional Well-being mean score before and after the intervention 81.8 vs 88.2 and 75.0 vs 90.2, respectively); The improvement of nutritional habits (Mediterranean Diet Scale mean score before and after the intervention 32.2 vs 34.2, respectively). Conclusion: Τhis pilot programme indicates that health professionals need to be vigilant in adapting falls prevention programmes effectively, even in unpredicted situations like the recent COVID-19 pandemic. The results were encouraging, since there were no falls incidents, the physical, the emotional well-being of the participants and their falls related knowledge and skills were improved.

P128: Post Hip Fracture Treatment: Evaluation of a Rehabilitation Hospital in Malta

M. Bonnici ^*1 , N. Ong ² , J. Cordina ¹ , and P. Ferry ¹

¹ Geriatric Medicine, Karin Grech Hospital, Pieta, ² Medicine, Mater Dei Hospital, Malta, Malta

Introduction: Hip fractures increase morbidity and mortality and an initial osteoporotic fracture is associated with an 86% increased risk of a subsequent fracture. The purpose of this quality improvement project was to assess whether patients admitted at a rehabilitation hospital were investigated and treated accordingly. Methods: The evaluation took form as a retrospective audit (December 2020), collecting data from January 2019 to December 2019 of 100 randomly selected patients admitted at a rehabilitation hospital in Malta. The standard used was the “NOGG 2017: Clinical guideline for the prevention and treatment of osteoporosis”. Data was collected from the patients’ hospital medical notes, electronic discharge letters and data (images and laboratory investigations). Each patient was given a code number for anonymity and data was inputted in a spreadsheet. Permission was obtained from the hospital’s research & ethics committee. Results: 74% of the population was female and 26% male. The mean age was 84 years, with a range of 66 to 98 years. The mortality rate at one year was 14%. 60% sustained an intertrochanteric fracture and 34% a femoral neck fracture. The mean Barthel score was 11.51 and 73% were still mobile. 22% had a previous fragility fracture. 74% were vitamin D deficient, 22% were vitamin D insufficient and 4% had a normal vitamin D status. 86% of the population was on vitamin D supplementation and 53% were on both vitamin D and calcium supplementation. 4 patients were started on bisphosphonates whilst as an in-patient or at follow-up. 2% were not willing to buy the osteoporotic treatment and 2% were previously on bisphosphonates but these had to be stopped due to side-effects. 41% were followed up by either a geriatrician or a general practitioner, with 4% refusing follow-up. The limitations were that some data collection depended on the patients’ medical notes which were not available for 40% of the patients and therefore the information was taken from the electronic discharge letter. Conclusion: There is still room for improvement in the secondary prevention of osteoporotic fractures. Two educational presentations were held amongst doctors and pharmacists working at the hospital. A post hip fracture pathway form was created to improve documentation and to also remind doctors on the steps needed for optimal management. Moreover, it will help in the continuity of care from hospital to the community. A re-audit will be conducted in 2022.

P130: Long-Term Persistence to Treatment After Hip Fracture in a Fracture Liaison Service

A. Naranjo ^*1,2 , A. Molina ¹ , F. Rubiño ¹ , A. Quevedo ¹ , F. Alonso ³ , and S. Ojeda ¹

¹ Rheumatology, HOSPITAL DE GRAN CANARIA DR NEGRIN, Las Palmas de Gran Canaria, ² Ciencias Médicas y Quirúrgicas, University of Las Palmas, LAS PALMAS DE G C, ³ Investigation Unit, Spanish Society of Rheumatology, Madrid, Spain

Introduction: Medium and long-term adherence to antiosteoporotic medication (AOM) in the setting of Fracture Liaison Service (FLS) and the related factors are not well known. The objective of this study is to analyze the long-term persistence of treatment in patients with hip fracture in a FLS. Methods: Our FLS began in 2012 and attend outpatient and inpatient with hip fracture in a nurse-led environment. Patients ≥ 50 years with a fragility hip fracture attended between 2012 and 2018 who were recommended for treatment to prevent new fractures were included. Baseline data included demographics, identification mode (outpatient vs inpatient) previous treatment and FRAX® items. Three to eight years later, patient records were reviewed and the following data were collected: (1) survival; (2) re-fracture; (3) initiation of treatment with antiosteoporotic medication (AOM), persistence and proportion of days covered (PDC). We selected a group of patients attended in our hospital for hip fracture in the first trimester of 2015 in which the FLS activity had to stop due to sick leave of the nurse. These patients followed standard care after hospital discharge. The adherence was obtained through the electronic records in the same way as the patients attended in the FLS. Results: We included 372 patients, mean age 79 years, 76% women, mean follow-up 47 months. During follow-up, 52 patients (14%) had a refracture (22 hip refractures) and 129 patients (34.5%) died. 283 patients (76.0%) started a treatment with AOM. Factors associated with start of AOM were previous treatment with a bisphosphonate (9.94; 95% CI: 1.29–76.32), T-score at the lumbar spine (0.80; 95% CI: 0.65–0.99), and age (0.94; 95% CI: 0.90–0.99). Persistence decreased to 72.6% at 12 months and 60% at 36 months. A PDC >80% was confirmed in 208 patients (55.7%), and associated with previous treatment with a bisphosphonate (OR 3.47; 95% CI: 1.37–8.77) and treatment with denosumab (OR 2.64; 95% CI: 1.35–5.17). Regarding 89 consecutive patients not attended by the FLS, mean age 80.7 years, 73% women, the persistence after discharge was as follows: At 3, 12, 24 and 36 months, 21.3%, 14.2%, 13.1% and 12.5%, respectively, were on treatment with AOM. Conclusion: Patients with fragility hip fracture attended at an FLS showed optimal long-term persistence (55% have PDC >80%) to treatment with of AOM. At 3 years, the persistence in FLS is 5 times greater than standard care.

P131: Parenteral Anti-Resorptive Therapy for Osteoporosis Management in a Tertiary Hospital in Kuala Lumpur

Z. Y. Y. Toh ^*1 , and T. Ong ¹

¹ Geriatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia

Introduction: Denosumab and Zoledronate are parenteral anti-resorptives (AR) used in osteoporosis. The aim of this project is to review their prescription and its adherence to safe prescribing. Methods: Patients ≥ 50 years with a new prescription in 2020 had data on their prescribing indication, and pre-treatment test collected and analysed. Pre-treatment assessment involved biochemical assessment 6 months prior to treatment initiation. Results: 170 patients from various Medical Clinics (Geriatric, Endocrine, Rheumatology), Primary Care and Orthopedic units were prescribed parenteral AR (Denosumab, 142/170, 83.5% and Zoledronate, 28/170, 16.5%). The mean age (SD) for the patients were 76.7 (9.1) years. 87.6% (149/170) prescriptions were indicated for post-menopausal osteoporosis. The other indications included osteoporosis in men (21/170, 12.4%), glucocorticoid induced osteoporosis (5/170, 2.9%) and Osteogenesis Imperfecta (1/170, 0.6%). 55.3% (94/170) of patients had prior oral bisphosphonate exposure, of which Alendronate was the most common. Indication for Denosumab were oral AR use >5 years (29.6%), new fragility fracture (18.3%), gastric intolerance (18.3%), physician decision (16.2%), worsening bone mineral density (BMD) (7.7%), poor compliance with oral AR (7.1%), and low creatinine clearance (2.8%). Indication for Zoledronate included gastric intolerance (39.3%), dementia or bed-bound (21.4%), onset of new fractures (21.4%), pill burden (14.3%) and worsening BMD (3.6%). Pre-treatment assessment of renal function was checked in 85.2% and 100% starting Denosumab and Zoledronate, respectively. 5.8% on Denosumab had a creatinine clearance <30 ml/min. Calcium and vitamin D (25-OHD) levels were done in 65.5% and 21.8% of those starting Denosumab; and 92.8% and 46.4% among those starting Zoledronate. 11.8% of those starting Denosumab were hypocalcemic. Vitamin D deficiency (<50 nmol/L) was detected in 38.7% (Denosumab) and 10.7% (Zoledronate), respectively. Conclusion: Multiple indication for parenteral ARs were seen in this analysis. Appropriate pre-treatment biochemical assessment was not done in all patients. Monitoring of drug safety with these potent AR is essential.

P132: Fragility Fracture Patients With a History of Prior Fractures More Likely to Present With Multiple Other Risk Factors: Findings From a Province-Wide Fracture Liaison Service

R. Sujic ^*1,2 , A. Yang ^1,2 , H. Ansari ³ , E. Bogoch ^2,4 , R. Jain ⁵ , J. Weldon ⁵ , and J. Sale ^1,3

¹ Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, ² Brookfield Chair in Fracture Prevention, St. Michael's Hospital, Unity Health Toronto, ³ Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, ⁴ Department of Surgery, University of Toronto,, ⁵ Osteoporosis Canada, Toronto, Canada

Introduction: Our objective was to examine whether fragility fracture patients presenting to a provincial fracture liaison service (FLS) with, versus without, a history of prior fractures differed in demographic characteristics and risk factors. Our secondary objective was to understand if those with a greater number of prior fractures differed from those with a single prior fracture. Methods: This cohort study included fragility fracture patients aged 50+ enrolled in the Ontario FLS between July 2017 and September 2019. Patients with, versus without, prior fractures were compared on age, sex, index fracture site, biological parent’s history of hip fracture, current fracture due to a fall, history of feeling unsteady when walking, history of falls in the past year, smoking, oral steroid use, and comorbid chronic conditions. Pearson’s Chi-squared, Fischer’s Exact, and Analysis of Variance tests were used to assess differences. Results: Among 14,454 patients, 16.8% (n = 2,428) reported a history of one or more prior fractures after the age of 40. These patients with prior fractures were significantly more likely to be older, female, with a greater number of comorbidities, greater incidence of falls, and they were more likely to feel unsteady when walking. Compared to those with one prior fracture, patients with a greater number of prior fractures were more likely to have a history of falls and feel unsteady when walking. Conclusion: Our study findings suggest that FLS fragility fracture patients who sustained prior fragility fractures are an important high-risk subgroup, associated with the presence of multiple risk factors, and warrant further attention within FLS priority pathways in order to disrupt their persistent fragility fracture cycle. 

P133: Teriparatide Use in a Tertiary Hospital in Kuala Lumpur

Z. Y. Y. Toh ^*1 , and T. Ong ¹

¹ Geriatrics, University Malaya Medical Centre, Kuala Lumpur, Malaysia

Introduction: Teriparatide is a second-line anabolic osteoporosis treatment. Its administration must adhere to local guidelines and recommendations. This study aims to review the adherence to prescribing recommendations of Teriparatide in our hospital. Teriparatide is indicated in those with T-score ≤ −2.5 with recurrent fragility fractures on 5–10 years of anti-resorptives or those with atypical femoral fractures.

Methods: Patients ≥50 years prescribed teriparatide in 2020 had data on their bone health history, prescribing indication, and pre-administration test checklist collected. Results: 37 patients mean age (SD) of 72.5 (9.2) years were prescribed teriparatide. This comprises 17.9% (37/207) of parenteral medications prescribed for osteoporosis management in the same year. 48.6% (18/37) had a prior osteopenia or osteoporosis diagnosis by bone mineral density (BMD) assessment. Only 21.6% (8/37) were on anti-osteoporosis treatment. The majority were on Alendronate and 8.1% (3/37) of them were on it for at least 10 years (median 12 years) prior to initiating teriparatide. A third of those not on treatment had a previous vertebral fracture. 62.1% (23/37) of teriparatide were initiated following an acute fracture (39.1% (9/23) hip fracture, 17.4% (4/23) vertebral fracture, 13.1% (3/23) peri-prosthetic fracture, 30.4% (7/23) other fractures). Other indication included osteonecrosis of the jaw and atypical femoral fractures associated with anti-resorptive exposure (2/37, 5.4%), severe spinal BMD (T-score -5.2; 1/37, 2.7%), and for off-label fracture healing (11/37, 29.7%). Prior to the initiation of teriparatide, calcium (30/37 patients, 81.1%), iPTH (2/37 patients, 5.4%), vitamin D (13/37 patients, 35.1%), alkaline phosphatase (32/37 patients, 86.5%) and renal profile (37/37 patients, 100%) were checked the preceding 6 months. When checked, the biochemical parameters were within the reference range, except 18.9% (7/37) had total 25-OH Vitamin D levels <50 nmol/L. Conclusion: A recent fracture and recurrent fractures places patients at increased risk of another fragility fracture. Teriparatide represents a small proportion of anti-osteoporosis treatment used. When prescribed, many did not adhere to the local checklist or osteoporosis guidelines. A review of local guidance and its prescribing is required.

P134: Individually Tailored Care Plan Improved Calcium Intake and Vitamin D Levels in Older Hip Fracture Patients

M. Pehkonen ^*1,2 , T. Luukkaala ^3,4 , M. Kujala ^1,5 , and M. Nuotio ^1,6

¹ Geriatric Medicine, University of Turku, ² Geriatric Medicine, Turku City Hospital, Turku, ³ Health Sciences, Tampere University, ⁴ Development and Innovation Centre, Tampere University Hospital, Tampere, ⁵ Geriatric Medicine, Seinäjoki Central Hospital, Seinäjoki, ⁶ Research Services, Turku University Hospital, Turku, Finland

Introduction: Ensuring sufficient calcium intake and serum vitamin D levels is essential part of fracture care and secondary prevention of subsequent falls and fractures. Many hip fracture patients have low vitamin D levels (assessed by serum 25(OH)D) at presentation and the amount of dietary calcium intake is commonly not known. We studied the effect of an individual care plan on calcium intake and 25(OH)D levels in older hip fracture patients. Methods: The study comprised population-based sample of 1001 Finns aged 65 and over sustaining a low energy hip fracture between 2011 and 2018. Follow-up data at geriatric outpatient clinic 4–6 months post-fracture were available on 796 patients. We assessed 25(OH)D levels and calcium intake from food and supplements in the acute post-fracture period. Calcium and vitamin D supplements along with nutritional advice were tailored individually. According to national guidelines for osteoporosis, the aim of daily calcium intake was 1000 to 1500 mg and the target range for 25(OH)D 75–120 nmol/l. Calcium intake and 25(OH)D were re-evaluated at the outpatient follow-up. The patients were categorized into living in their own home with or without organized homecare, and living assisted or institutionalized. Results: The pre-fracture calcium intake was below recommendation in half (52%) of the patients. This was particularly evident in patients living in their own homes. In this group calcium intake improved significantly^† in the post-fracture period (median change 780 to 830 mg, interquartile ranges (IQRs) 540–1200, 600–1040). In the group of assisted or institutionalized living calcium intake was already higher and did not improve significantly. Daily intake exceeded the recommendation in 16% of the patients. In 60% of the patients the 25(OH)D level was below the target range for osteoporosis and 36% had hypovitaminosis (<50 nmol/l). D vitamin supplement was in use in 40% before the fracture. In the post-fracture period 25(OH)D increased to the recommended therapeutic area in majority of patients living both in their own homes^† (median 25(OH)D 57 vs 87 nmol/l, IQR 38–79 vs 70–108) and assisted or institutionalized^† (median 25(OH)D 65 vs 86 nmol/l, IQR 50–86 vs 76–107). True vitamin D deficiency became less common towards the end of the study period. (^†P < 0.001). Conclusion: Individually tailored care plan improved calcium intake and vitamin D levels in older hip fracture patients. Primary prevention was more successful in patients living assisted or institutionalized.

P135: Towards Better Insights: Preliminary Results of a Machine Learning Model for Fracture Risk Assessment

E. Sykes ^*1 , R. Jain ² , A. Canales ¹ , W. B. Wang ¹ , M. Deol ¹ , J. Weldon ² , R. Shanker ³ , V. Voytenko ¹ , J. Sullivan ³ , and D. Sauer ³

¹ Centre for Mobile Innovation, Sheridan College, Oakville, ² Ontario Osteoporosis Strategy, Osteoporosis Canada, Toronto, ³ Inovex, Oakville, Canada

Introduction: Fracture risk assessments are essential to evaluate and prevent osteoporotic fractures. While it is desirable to collect all relevant data about patients regarding their susceptibility to fractures to make an accurate assessment, in real-world environments osteoporosis patient data can be incorrect, inconsistent, or missing.  A crucial component to calculating the fracture risk is the Bone Mineral Density (BMD) T-score (used in fracture risk calculators: e.g., FRAX, CAROC).  BDM tests are conducted at hospitals or medical clinics at the request of a physician. However, many people don’t get tested.  In some areas only 50% of the people show up for the test. We created a Machine Learning (ML) model that predicts the BMD T-score based on other relevant patient osteoporosis features to assist professionals to assess the fracture risk when limited information is available. Methods: Osteoporosis Canada (OC) dataset:  The OC dataset has 26,804 screened fragility fracture patients from 39 hospital sites. A single patient contains 200 features, from which 29 were selected for our ML research (e.g., age, gender, weight, fracture history, etc.).  Only a small set of representative data were available (245 records) due to security and privacy reasons. As a result, we created a synthetic data generator to expand our training data for our ML research. Our synthetic data generator creates representative patient data for the 29 features based on: OC reports, osteoporosis research articles, and advice from osteoporosis experts.  ML: The following ML algorithms were explored: decision trees, SVM, and linear regression. 80% of the data were used for training and 20% for testing. Evaluation: Confusion matrices and derivations (i.e., accuracy, sensitivity, precision and F1-score) and the root-mean-square error (RMSE) were used to evaluate our ML models. Results: Among the ML models created, the linear regression model performed the best.  This model was tested on 25,000 synthetic patient data and performs at an accuracy = 94.11%, sensitivity = 75.63%, precision = 91.66%, F1-score = 75.61% with RMSE = 4.22 (σ = 0.413).  The model was also tested on 245 real patient data and performed at an accuracy = 98.49%, sensitivity = 73.24%, precision = 97.39%, F1-score = 84.55% with a RMSE = 0.886 (σ = 0.441). Conclusion: We created an ML model that can predict the BMD T-score based on other relevant patient osteoporosis data to assess the fracture risk (low, moderate or high) based on limited features available in real-world situations.

P136: Patients Experience a Need For Informal Care After a Fragility Fracture

J. Sale ^*1,2 , L. Frankel ¹ , W. Yu ¹ , J. Paiva ¹ , J. Saini ¹ , S. Hui ¹ , E. Bogoch ¹ , and L. Meadows ³

¹ Unity Health Toronto, ² University of Toronto, Toronto, ³ University of Calgary, Calgary, Canada

Introduction: Care needs after a fracture may be significant. Previous reports have demonstrated that long-term consequences of fracture include pain, depressive symptoms, fracture-related limitations, and re-admission to hospital. In individuals with hip and non-hip fragility fractures, our objectives were to examine: (1) the experience of receiving informal care post-fracture; and (2) how these care experiences influenced post-fracture recovery and subsequent management of bone health. Methods: A secondary analysis of six primary qualitative studies was conducted. Individuals in the primary studies were English-speaking women and men, 45 years and older, who were living in the community and had sustained a recent fragility fracture or reported a history of previous fragility fractures. Participants who reported at least one instance of needing informal care were categorized as receiving “enough care”, “insufficient care”, or “no care”. Results: Of 145 participants in the primary studies, 109 (75%) described needing informal care after their fracture (20 hip fractures, 89 non-hip fractures). Of those needing care, 62 (57%) were categorized as receiving enough care while 47 (43%) were categorized as receiving insufficient or no care. The care needed affected the management of participants’ fracture and bone health, including access to health care services. Participants who received insufficient or no care, especially those living alone, devised strategies to care for themselves and often requested help from multiple individuals to minimize the burden to family and friends. Compared with men, women appeared to report needing help with personal daily activities, such as bathing, and transportation to appointments related to bone health. Conclusion: Informal care needs are an additional burden of fragility fractures. Post-fracture interventions should consider the broader context of patients’ lives and potentially support the care needs of patients as part of their services.

P138: Improving Vertebral Fracture Identification – A Joint Project Between Radiology and a Fracture Liaison Service

R. James ^*1

¹ Somerset Foundation Trust, NHS, Taunton, UK

Introduction: Vertebral fractures are the most common of osteoporotic fractures and can have a huge impact upon patients as well as a financial burden to health services. Up to 70% of vertebral fractures remain undiagnosed and early identification is a priority of fracture liaison services (FLS) in the UK. Radiology imaging is an opportunity to use routine imaging to identify previously undiagnosed vertebral fractures. Currently incidental findings of vertebral fractures may not be routinely reported on in radiology reports or referred on to fracture prevention services such as FLS. In early 2019 our hospital embarked upon a joint project between Radiology and FLS to use Radiology software to improve our incidental findings of vertebral fractures. This poster will aim to look at our process and journey of implementing these improvements. Methods: The aim of the project was to use a radiology picture archiving and communication system (PACS) function which allows the reporting clinician to flag critical findings urgently to the referrer, a critical report notification (CRN). The reporting clinician would assess the spine in each eligible scan and if a vertebral fracture was present a CRN would be placed against the patient report. This would be picked up by the radiology assistants who would notify FLS The only costs associated with this system were with the reporting clinicians, FLS practitioners and radiology assistants extra time. Results: Using the fracture liaison service database records, in 2018 our vertebral fracture identification was around 18% (national average 15%). In 2019 this increased to 77% (national average 24%) and 2021 data to date shows that we are routinely identifying around 100% of expected vertebral fracture numbers. Interestingly identification rates were initially correlated with FLS presence at radiology education sessions and email correspondence with the radiology team, with rates increasing after each interaction. Conclusion: The results suggest that continuous collaborative working between radiology and FLS is an effective tool to positively affect the number of incidental vertebral fracture patients identified. Education and continuing feedback and collaboration appears to be key in keeping identification rates in line with departmental expectations. Not only is this a cost effective tool, but may also have a positive impact upon our patients and their quality of life for years to come.

P139: Atypical Femoral Fractures – A Case Series

P. Lalor ^*1 , G. Steen ¹ , N. Fallon ¹ , C. O'Carroll ¹ , N. Maher ¹ , R. Lannon ¹ , and K. McCarroll ¹

¹ Geriatrics, St James Hospital, Dublin 8, Ireland

Introduction: Atypical femoral fractures (AFF) are a rare type of subtrochanteric stress fracture associated with long term bisphosphonate use. Though rare, incidence rises after 5 years of therapy affecting up to 1 in 800 patients. AFF can be incomplete but can propagate transversely or obliquely, with little or no comminution (complete AFF). Fracture may occur with little or no trauma, be preceded by prodromal pain and affect the contralateral femur (25%). However, optimal management of patients with AFF is not clearly established. We report on a case series of patients with AFF at our hospital. Methods: We searched our bone heath database (within the last 10 years) for patients with a diagnosis of AFF (complete or incomplete). All cases were reviewed to ensure the diagnosis was consistent with ASBMR criteria. We then collated relevant clinical data regarding presentation, duration of bisphosphonate use and patient treatment. Results: We identified 12 patients, all were female, and mean age for AFF was 71.5 years (range 54 to 83). Ten were on oral bisphosphonates and two on intravenous therapy. Mean duration of treatment was 8.7 years (range 4 to 12). 10 presented with complete AFF and 2 incomplete AFF. However, contralateral incomplete AFF was identified in 5 patients who presented with a completed fracture and in one with incomplete AFF. Seven patients reported prior prodromal thigh pain. Of complete AFFs, 9 were sustained from a simple fall while one was spontaneous. All complete AFFs were treated with surgical fixation and six with teriparatide, though three stopped due to side effects. All patients with incomplete AFF were considered for prophylactic femoral nailing – 2 had it done, 2 healed on teriparatide alone and 4 remain under close monitoring. One patient had non-union of a complete AFF after surgery despite two years of teriparatide therapy. Conclusion: These cases are a reminder of the need for judicious use of bisphosphonates beyond five years. It also highlights the importance of identifying incomplete AFF in any patients with thigh pain and who is on bisphosphonate therapy. Some evidence supports a role for teriparatide in reducing time to healing in patients with complete AFF though non-union can still occur. Prophylactic femoral nailing should generally be done in incomplete AFF, especially if there is a visible fracture line, pain or ongoing use of steroids, though healing may occur spontaneously on withdrawal of bisphosphonates.

P140: Documented History of Fragility Fracture to Improve Secondary Fracture Prevention in Geriatric Patients

L. Welthy ^*1 , D. Ziyebangwa ¹ , A. Muza ¹ , and H. Seymour ²

¹ Orthopaedic / Trauma, ² Ortho-geriatrics, WA South metro Health service, Perth, Australia

Introduction: Aging is the most significant risk factor for osteoporosis. Osteoporosis is often only first apparent when patients present with a fragility fracture. However, clinicians often fail to recognise this as a diagnosis of osteoporosis, and it remains severely under-diagnosed and treated. As a result, in Australia, 1 in 2 women and 1 in 3 men over the age of 60 will have an osteoporotic fracture. This project aimed to determine if accurate history taking and review of routine investigations during admission would capture patients who would benefit from secondary fracture prevention if osteoporosis could be diagnosed. Methods: A point prevalence survey was conducted across both sites. Auditing patients admitted under geriatrics. A review of documented medical history, patient questionnaires, and radiological examinations were completed. Documentation was analysed for a history of a fragility fracture, known osteoporosis and current treatment for osteoporosis. The questionnaire included it the patient had a previous fragility fracture, known diagnosis of osteoporosis and previous bone mineral density. The questionnaire excluded cognitively impaired patients or if the information was unknown. Lastly, we looked if the patient had an anteroposterior chest x-ray that could be used to identify vertebral fractures. This data was analysed to evaluate the percentage of patients who could be diagnosed and treated for osteoporosis based on a history of fragility fracture, to determine if accurate history was being recorded and if chest x-ray could be used as a diagnostic tool. Results: 132 patients were identified. 35.5% of patients had a documented previous minimal trauma fracture compared to 19.7% on the questionnaire (28.8% unknown). 15.7% had a documented diagnosis of osteoporosis however, 17.4% of patients stated they had been told they have a diagnosis of osteoporosis (44.7% unknown). Only 16% of patients were on treatment. 14.4% of patients had a previous bone mineral density scan (48.5% unknown). Additionally 93.3% of patients had an anteroposterior chest x-ray. Conclusion: Verbal history is somewhat consistent with documentation of previous. However, 19.5% of patients sustaining previous fragility fracture were not receiving treatment. Clinicians are failing to recognise fragility fracture as a diagnosis of osteoporosis. Nearly all the patients admitted had a chest x-ray that could have been used to identify vertebral compression fractures diagnostic of osteoporosis.

P141: Osteoporosis Management and Secondary Fragility Fracture Risk in Patients With Multiple Sclerosis: A Matched Cohort Study

B. Ross ^*1 , A. Ross ¹ , O. Lee ¹ , and W. Sherman ¹

¹ Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, USA

Introduction: Patients with multiple sclerosis (MS) are known to be at high risk for osteoporosis and fragility fractures. However, rates of secondary fractures and the efficacy of osteoporosis treatment after primary fragility fractures for patients with MS is unknown. The purpose of this study was to compare rates of osteoporosis management, falls, and secondary fractures following sentinel fragility fractures among patients with MS versus matched controls. Methods: A retrospective matched cohort study was conducted using the PearlDiver database (Fort Wayne, IN, USA). Patients aged 50 years and older presenting with primary fragility fractures of the hip, spine, pelvis, wrist, proximal humerus, and other locations were identified using ICD-9/10 diagnosis codes. Within this cohort, patients with MS were matched 1:10 with controls across the following variables: age, sex, and U.S. region. Rates of DEXA screening, osteoporosis diagnoses (via ICD-9/10 diagnosis codes), osteoporosis treatment, low-energy falls, and secondary fractures were compared at 3-year follow-up via multivariable logistic regression. Results: Of 120,368 identified primary fragility fractures, 1,232 (1.0%) patients with MS were matched with 12,320 controls. Index fractures of the hip were significantly more common in the MS cohort (47.4% vs. 34.2%, P < 0.001) while primary fractures of the wrist (17.0% vs. 27.5%, P < 0.001) and humerus (13.3% vs. 16.3%, P = 0.006) were significantly more prevalent in the non-MS cohort. At 3-year follow-up, patients with MS were significantly more likely to have been diagnosed with osteoporosis (12.9% vs. 9.7%; OR 1.35; 95% CI 1.13–1.61) and received osteoporosis pharmacotherapy (14.4% vs. 11.9%; OR 1.24; 95% CI 1.04–1.46). The MS cohort was also significantly more likely to experience a fall (27.8% vs 22.7%; OR 1.15; 95% CI 1.01–1.32). Rates of secondary fractures were higher in the MS cohort (6.3%) than the non-MS cohort (5.0%) but not significantly more likely (OR 1.10; 95% CI 0.85–1.40). Conclusion: Following a primary fragility fracture, patients with MS were significantly more likely to experience a fall and exhibited a higher secondary fracture rate at 3-year follow-up versus matched controls. However, MS patients were also significantly more likely to be diagnosed and treated for osteoporosis. This data may suggest that increased secondary fracture risk in patients with MS can be mitigated by adequate osteoporosis evaluation and management.

P142: Treatment Outcomes of Patients Who Fractured While on Bone Active Medications

R. Sujic ^*1,2 , A. Yang ^1,2 , E. Bogoch ^2,3 , R. Jain ⁴ , J. Weldon ⁴ , and J. Sale ^1,5

¹ Musculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, ² Brookfield Chair in Fracture Prevention, St. Michael's Hospital, Unity Health Toronto, ³ Department of Surgery, University of Toronto, ⁴ Osteoporosis Canada, ⁵ Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada

Introduction: Our objective was to examine characteristics of fragility fracture patients from an Ontario Fracture Liaison Service (FLS) who fractured while taking bone active medication and to assess their medication prescription at follow up. Methods: The analysis included FLS fragility fracture patients aged 50+ who were taking bone active medication when they fractured and who saw a specialist as part of an Ontario FLS. The patients were enrolled in the FLS between Aug 10, 2017 and February 14, 2020. We used the cut-off date of June 30, 2020 to collect outcomes. We first examined the baseline characteristics of patients who reported taking bone active medication at the time of fracture and compared them to the baseline characteristics of all other patients who also had specialist outcome data. We then examined the medication prescription outcomes of those who fractured while taking medication. Results: There were 2264 patients aged 50+ who had seen a specialist and who had follow-up data collected from the specialist’s office. Of these, 17% (n = 387) were patients who sustained an index fracture while on bone active medication while 83% (n = 1877) were patients not taking bone active medication at the time of their index fracture. These two groups of patients were similar in terms of age, sex, index fracture location, history of falls and the number of comorbid chronic conditions. Of 387 patients who fractured while taking medication, 47% (n = 181) reported taking Risendronate, 20% (n = 78) reported taking Prolia and 16% (n = 60) reported taking Fosamax. At the time of follow up with a specialist, of 387 patients, 56% (n = 216) were advised by their specialist to switch to another medication, 39% (n = 152) were advised to remain on the same medication, and 3% (n = 13) were advised to discontinue medication. Data were not available on the remaining 2%. The majority of patients who were advised to switch medication were prescribed Prolia (n = 189, 88%), followed by Forteo (n = 14, 6%), Actonel (n = 10, 5%) and other. Less than five patients (2%) refused the specialists’ prescription. Conclusion: We examined follow-up data of Ontario FLS patients who fractured while taking bone active medication and found that the majority of patients were advised by their specialist to change their medication. These results shed light on treatment outcomes of a group of patients that are generally not the focus of FLS screening and suggest that there is a value in assessing their outcomes.

P143: Promoting the Measurement of Lying and Standing Blood Pressure to Improve Multifactorial Falls Assessment and Prevention of Falls

S. Fouda ^*1 , E. Dominguez ¹ , T. Sivagnanam ¹ , and S. P. Sheriff ¹

¹ Care of the Elderly, Aneurin Bevan University Health Board, Newport, Wales, UK

Introduction: Orthostatic Hypotension (OH) is a common and disabling condition among older patients which can result in falls with significant morbidity and mortality. Increasing the incidence of falls in hospitals and in the community requires early identification and management of OH. The aim of this study is to assess how well orthostatic blood pressure monitoring is recorded and whether this could be improved. Methods: We conducted a prospective study in 5 geriatric wards including three cycles. We audited the notes of inpatients presented with falls, had inpatient falls, history of recurrent falls or deemed to be at high risk of falls. Logged whether lying and standing blood pressure (L/S BP) was done, this was done correctly and clearly documented. Both of the medical and nursing teams were contacted following the first cycle and a pro forma sheet was introduced including guidance on performing L/S BP. In addition, the second cycle was followed by a teaching session, reminder emails to the ward managers and out-reach visits to wards to educate and encourage the recording of L/S BP. Results: The first cycle included a total of 65 patients and showed a percentage of 13.84 who had their L/S BP done compared to 34.54% among 55 patients in the second cycle. While the third cycle included 56 patients, 57.14% had their measurements done. Among those who had orthostatic blood pressure, it was done correctly in 44% in the first cycle and it was improved to 57% and 75% in respective cycles. It’s worth mentioning, all those identified with OH had a successful or ongoing medical management. Following this project, the concise format of lying and standing blood pressure monitoring was included in the updated Multifactorial Falls Assessment booklet for the health board (Aneurin Bevan University Health Board). Conclusion: Interventions done to educate about and promote the monitoring of L/S BP through teaching, reminder emails and pro forma introduction resulted in a significant improvement of the recording, accurate measurement and management of OH as a part of multifactorial falls assessment and prevention.

P144: The Effects of Combination Therapy With Low-Dose Romosozumab and Active Vitamin D3 on Fracture Healing in Ovariectomized Rats

R. Takase ^*1 , Y. Tsubouchi ¹ , O. Takefumi ² , T. Kataoka ¹ , S. Ikeda ^{1, 3} , M. Kataoka ⁴ , and H. Tsumura ³

¹ Department of Rehabilitation, Oita University Hospital, Yufu, ² Department of Innovative Enfineering, Oita University, Oita, ³ Department of Orthopaedic Surgery, Oita University, Yufu, ⁴ Faculty of Welfare and Health Sciences, Oita University, Oita, Japan

Introduction: In this study, we investigated the accelerate fracture-healing and bone mineral density-increasing effects of combination therapy with low-dose romosozumab and active vitamin D₃ on fractures in ovariectomized rats. Methods: Ovariectomy was performed on forty 24-week-old female Sprague–Dawley rats. After eight weeks, the rats underwent removal of the periosteum and osteotomy of the femoral shaft followed by osteosynthesis with intramedullary nailing to create an open fracture model. One week postsurgery, 40 rats were divided into four groups {C group, R group [romosozumab 25 mg/kg, a subcutaneous (sc) injection/month], VD group (active vitamin D₃ 0.2 µg/kg, two times sc injections/week), R + VD group}.In addition, 10 rats were categorized as the sham group. Ten weeks postintervention, both femurs were removed, and blood was collected. Soft X-ray imaging was used to evaluate bone union, and micro-computed tomography (micro-CT) was used for bone morphometric evaluation. Toluidine blue staining of undecalcified specimens was used for histopathological evaluation, and bone turnover marker levels were measured by enzyme-linked immunosorbent assay. Results: Bone morphometry analysis with micro-CT revealed an increased mineral density of the trabecular bone, demonstrating the effectiveness of combination therapy with low-dose romosozumab and active vitamin D₃. However, no differences in callus increase and bone union evaluated by soft X-ray imaging were observed, demonstrating no acceleration of fracture-healing. Conclusion: Although combination therapy with low-dose romosozumab and active vitamin D₃ increased the trabecular bone mineral density, it might not accelerate fracture-healing. This effect might not be observed regardless of romosozumab dose.

P145: Physical-Functional Tests and Sarcopenia: What Do They Tell Us About Recurrent Falls?

A. D. S. Passos ^*1 , A. Sanudo ² , E. Ishigaki ³ , M. A. Zambone ³ , S. Pena ⁴ , T. Sampaio ³ , S. Paschoal ³ , M. Perracini ⁵ , and L. E. Garcez-Leme ³

¹ Universidade de São Paulo, Sorocaba, ² Universidade Federal de São Paulo, ³ Universidade de São Paulo, Sao Paulo, ⁴ Universidade Federal do Mato Grosso do Sul, Mato Grosso do Sul, ⁵ Universidade Cidade de São Paulo, Sao Paulo, Brazil

Introduction: Falls are deleterious events for the health of the elderly, resulting in high morbidity and mortality, reduced quality of life and high costs to the public and private health system. Sarcopenia screening and the physical-functional assessment of fallers may reflect which tests are important in the practice of implementing a fall prevention protocol, since it is known that such factors directly impact the number of these events. Methods: The variables that represent the physical-functional tests (timed up and go test, sit to stand test, gait speed test) and screening for individuals with sarcopenia were analyzed using the chi-square test. All that had p-value ≤ 0.20 were included in the final model, adjusted by logistic regression analysis. To find out whether the association with recurrent falls between the variables positive screening for sarcopenia and sit to stand test > 12sec was independent, a stratified analysis of the variables was performed. Positive screening for sarcopenia was defined as the association between low muscle strength (handgrip: <16kg for women and <26kg for men) and low muscle mass (calf-circumference: ≤33cm for women and ≤34cm for men). Recurrent falls was defined as the presence of two or more falls in the last 12 months. Results: 715 individuals analyzed (67.8% had recurrent falls; 69.4% were female; 59.8% white). Mean age 73.44 years. The chi-square test showed a positive relationship between timed up and go test > 13.5 sec (OR 1.77, 95% CI 1.18–2.66, P = 0.005); sit to stand test > 12sec (OR 1.57, 95% CI 1.13–2.19, P = 0.007); gait speed test < 0.8m/sec (OR 2.02, 95% CI 1.29–3.17, P = 0.002) and positive screening for sarcopenia (OR 1.91, 95% CI 1.09–3.33, P = 0.022 ) with recurrent falls. After adjustment of the final model by logistic regression analysis and stratified analysis, the variables positive screening for sarcopenia (OR 2.09, 95% CI 1.18–3.71, P = 0.012) and sit to stand test > 12 sec (OR 1.49, 95% CI 1.06–2.10, P = 0.020) were independently associated with recurrent falls. Model adjusted for sex, polypharmacy, psychotropic drug use, monthly income, fear of falling and concern about falling (FES-I scale). Conclusion: Positive screening for sarcopenia, sit to stand test > 12 sec have shown to be independently associated with recurrent falling. These two variables are essential in a fall prevention assessment protocol as the minimum to be evaluated quickly, safely for the elderly and consistent with the world literature on this topic.

P146: Promoting the use of Hip Protectors in Care Facilities Through a Structured Staff Training Programme

K.-C. W. Leung ¹ , Y.-J. Yang ^*1,2 , S.-H. P. Yung ³ , and W.-H. L. Cheung ³

¹ Department of Sports Science and Physical Education, ² CUHK Jockey Club Institute of Ageing, ³ Department of Orthopaedics and Traumatology, The Chinese University of Hong Kong, Hong Kong, China

Introduction: Falls cause up to 95% of geriatric hip fractures, of which the rates are two- to three-fold higher in long-term care. Although hip protectors have been proven effective against fall-related hip fractures, the use of hip protectors in Hong Kong care facilities remains very low (<5%). Recent studies have shown that user compliance can be facilitated when care staff are committed to supporting the use of hip protectors. Therefore, the objective of this project is to enhance hip protector compliance in care facilities through structured staff training. Methods: Ninety-four care workers from four nursing homes and one day-care centre attended a 60-minute educational session on the epidemiology of hip fractures and related consequences, strategies to prevent falls and hip fractures, and effectiveness and strategies for successful implementation of hip protectors. After each session, facilitators of and barriers to hip protector acceptance were surveyed by a self-administered questionnaire. Common themes were clustered according to the socio-ecological model. To examine the effectiveness of the education programme on user compliance, free hip protectors were provided to 39 residents from two nursing homes, where one (n = 28) received both free hip protectors and educational session, and the other one (n = 11) was only fitted with free hip protectors. Resident compliance in wearing hip protectors (initial acceptance and sustained adherence) was evaluated over 6 months. Results: Overall, the staff education sessions were rated 6.0 out of 7.0 (>85%). After the sessions, 52.1% of care workers agreed that hip protectors can prevent fall-related hip fractures. On the other hand, residents’ noncompliant behavior (e.g. great reluctance to accept new things) (48.9%) was the major barrier to the initial acceptance in care facilities. At caregiver and product levels, lack of staff and family advocacy (7.4%) and high monetary cost (6.4%) were significant obstacles that refrain residents from using hip protectors. As opposed to a nursing home without receiving staff training [36.4% (4/11)], the staff education session increased the initial acceptance to 89.3% (25/28). However, preliminary data showed a low adherence rate [36.0% (9/25)] over a 6-month observation period. Conclusion: A structured staff education programme increased the use of hip protector by >50% in care facilities in Hong Kong. However, strategies for sustaining long-term adherence of wearing hip protectors should be guaranteed in this setting.

P147: Regional Bone Metabolism in Postmenopausal Osteoporotic Women Treated With Either Alendronate or Teriparatide

B. Garg ^*1 , V. Dixit ¹ , N. Mehta ¹ , G. Parida ² , H. C. Sati ³ , R. Kumar ² , and R. Malhotra ¹

¹ Orthopedics, ² Nuclear Medicine, ³ Biostatistics, All India Institute of Medical Sciences, New Delhi, India

Introduction: Postmenopausal osteoporosis is a global public health concern. Monitoring treatment response to pharmacotherapy for osteoporosis can be helpful in determining superior of an anti-osteoporotic regimen. Methods: Thirty-six postmenopausal women with osteoporosis were prospectively recruited. Osteoporosis was diagnosed by DXA scan. Patients were randomized into two treatment groups (Group TP & Group AL): patients in Group TP were treated with subcutaneous teriparatide (TP) injection (20µg/day), whereas patients in Group AL received 70mg weekly oral alendronate (AL) with standard calcium and vitamin D doses. Quantitative bone scan images were assessed to determine regional bone uptake at baseline, 3^rd, 12^th and 18^th months of therapy with either TP or AL. Bone turnover markers were also estimated at scheduled follow-ups. Statistical analysis was done by using two-sample Wilcoxon rank-sum test for statistical comparison in two groups. Results: The baseline values were comparable in both the groups. The values of regional bone uptake at different skeletal sites including calvarium, spine, pelvis, lower extremity and upper extremity were not statistically significant in both the groups. However, patients who received TP therapy, the values of whole skeleton were statistically significant (P = 0.022). The values of bone turnover markers were not statistically significant with the correspondence values of regional bone scan. Conclusion: Although both TP and AL provide comparable results for the treatment of osteoporosis but based on bone uptake values through quantitative bone scan, TP therapy was found better than AL for the improvement at specific bone regions. Further studies with large sample size are needed to substantiate our findings.

P148: Differential Mirna Expression in Osteoporotic Elderly Patients With Hip Fractures Compared to Young Patients

B. Garg ^*1 , R. Malhotra ¹ , S. Mittal ² , A. Kumar ¹ , N. Mehta ¹ , G. Malik ¹ , M. Gupta ¹ , and V. Trikha ²

¹ Orthopedics, All India Institute of Medical Sciences, ² Orthopedics, Jai Prakash Narayan Apex Trauma Centre, New Delhi, India

Introduction: The expression pattern of micro RNAs (miRNA) has been implicated in the pathomechanism of various bone disorders and has a role in differentiation of osteoblasts and osteoclasts. The purpose of the study was to investigate the differential miRNA profiles of osteoporotic hip fractures compared to young patients with hip fractures. Methods: Blood samples from ten osteoporotic patients and ten young healthy patients, presenting with acute hip fractures were collected and subjected to an initial miRNA profiling to detect those miRNAs with significant variations between the two groups based on polymerase chain reactions performed in duplicate. A real-time quantitative polymerase chain reaction-based analysis was then performed for validation of specific miRNAs that were significantly different between the two groups. Results: A total of 182 miRNAs were analyzed. Thirty-nine of them showed significant differences between the two groups in the initial miRNA profiling. The validation results suggested that five miRNAs related to bone metabolism had significantly different expression among the osteoporotic hip fracture group compared to the young healthy group: miR-23b-3p and miR-140-3p were up-regulated; and miR-21-5p, miR-122-5p and miR-125b-5p were down-regulated. Conclusion: Our findings point towards the heterogeneity of the currently available evidence concerning the miRNA changes in osteoporosis and osteoporotic hip fractures, and a possible role of additional factors contributing to the miRNA changes in osteoporosis and osteoporotic hip fractures. Further research is required to elucidate the mechanism of their involvement in osteoporosis.

P149: Assessing Current Trends in Primary Care Beliefs Towards Vertebral Compression Fractures

C. Nic Gabhann ^*1 , P. McCarroll ¹ , M. Curtin ¹ , F. Rowan ¹ , and M. Cleary ¹

¹ Orthopaedics, Univeristy Hospital Waterford, Waterford, Ireland

Introduction: Vertebral compression fractures (VCFs) are increasing in number with the aging population. They largely go undiagnosed and undertreated, increasing chronic pain, hospitalisation and mortality among patients. The costs of these osteoporotic vertebral fractures are estimated to be in excess of 300 million euro by the year 2046. In an effort to reduce the burden on the health service, a shift towards community care has been observed in other countries; however, the literature on the treatment is ambiguous. Methods: A comprehensive multiple-choice survey was designed and sent to general practitioners (GPs) in the University Hospital Waterford geographical catchment area. Questions were designed to gather information on participant profile, clinical background, and their knowledge on VCFs. Information on the knowledge of treatment modalities was also obtained. Results: The majority of GPs (59.7%) correctly identified VCFs as the most common fragility fracture, knew that VCFs are common after low impact trauma and are associated with multiple complications. Although there was a unanimous understanding that bone health plays a role in the treatment of VCFs, there was a divide on management of refractory pain including vertebral augmentation.  There was a significant underestimation of the burden of illness that VCF have on the tertiary referral centre. Conclusion: This study identifies a lack of understanding that exists in the primary care setting with regards VCF treatment, and it prompted the development of a pilot clinical care pathway. The aim is that it be rolled out nationally as an aid to the diagnosis and management of VCFs in the community, with a goal of reducing the burden associated with these fractures to the health service. 

P150: Degenerative Changes in Lumbar Spine Are Less Prevalent and Less Severe in Elderly Hong Kong Chinese Women Than in Age-Matched Italian Caucasian Women: A Cross-Sectional Radiographic Study

T. Y. So ¹ , D. Diacinti ² , J. C. Leung ¹ , A. Iannacone ² , E. Kripa ² , T. C. Kwok ¹ , D. Diacinti ² , and Y. X. J. Wang ^*1

¹ Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, ² Sapienza University of Rome, Rome, Italy

Introduction: In our recent cross-sectional spine radiograph study with population based elderly females (mean: 74.1 yrs), we noted that Chinese subjects (n = 200) had osteoporotic endplate/cortex fracture (ECF) in 26% cases involving 3.54% of the T4-L5 vertebrae, while Italian subjects (n = 200) had ECF in 47% cases involving 8.21% of T4-L5 vertebrae. Osteoporotic vertebral fracture (OVF) in Chinese women tends to be less common, less severe and less likely to be multiple. In this study we aim to perform a quantitative comparison of lumbar degenerative changes between Italian and Chinese women. To date, there are few reports comparing these changes between East Asians and Caucasians. Methods: Lumbar spine radiographs of age-matched (mean: 74.3 yrs; range: 67–84 yrs) female subjects from two population-based epidemiological studies from Hong Kong (n = 130) and Rome, Italy (n = 130) were reviewed. Analysis and classification of disc height loss (none, <30%, 30–60%, >60%), osteophyte formation (not present, minimal, small, large), endplate sclerosis (none, mild, moderate, severe), and antero/retrolisthesis (none, <25%, 25–50%, >50%) was performed for each vertebral level from L1/2-L5/S1 (total, 5 levels). Each individual finding was assigned a score (0, 1, 2, 3) based on its classification of severity for each vertebral level, and the total degeneration score was obtained by adding scores for the findings across all vertebral levels. Results: Italian subjects (total score [mean±SD], 9.42 ±5.38) had higher severity of overall degenerative changes compared to Hong Kong subjects (total score [mean±SD], 7.46 ±4.77) (P = 0.03). Italian subjects had higher scores for all individual findings (Italian disc height loss [mean±SD], 4.70 ±2.64, vs. Hong Kong disc height loss [mean±SD], 3.25 ±2.24; Italian sclerosis [mean±SD], 1.22±1.27 vs. Hong Kong sclerosis [mean±SD], 0.79±1.09; Italian antero/retrolisthesis [mean±SD], 0.48±0.77 vs. Hong Kong antero/retrolisthesis [mean±SD], 0.28±0.60), apart for osteophytes (Italian disc osteophytes [mean±SD], 3.01 ±2.41 vs. Hong Kong osteophytes [mean±SD], 3.12±2.58). The prevalence of moderate to severe degeneration at any one level (level score≥5), was higher in Italian compared to Hong Kong subjects (Italian, 5.31% vs Hong Kong, 2.23%). Conclusion: Degenerative changes in the lumbar spine are less prevalent and less severe in elderly Hong Kong Chinese women than in age-matched Italian Caucasian women.

P151: Much Lower Prevalence and Severity of Radiographic Osteoporotic Vertebral Facture in Elderly Hong Kong Chinese Women Than in Age-Matched Rome Caucasian Women: A Cross-Sectional Study

Y. X. J. Wang ^*1 , D. Diacinti ² , J. C. Leung ¹ , A. Iannacone, ² , E. Kripa, ² , T. C. Kwok ¹ , D. Diacinti, ²

¹ Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong, ² Sapienza University of Rome, Rome, Italy

Introduction: Many studies reported that East Asian and Caucasian have similar radiographic osteoporotic vertebral fracture (OVF) prevalence. However, it is estimated that ¾ of the vertebral fractures are clinically silent, and diagnosis of true OVF on radiograph is challenging. Much of OVF prevalence differences among different studies is expected to be due to the inconsistence of OVF assessment. Since elderly Chinese’s osteoporotic hip fracture prevalence is half (or less than half) of that of their age-match Caucasians, we hypothesize that elderly Chinese OVF prevalence could be only half, or even less than half, of that of their age-match Caucasians. Methods: Age-matched (mean: 74.1 yrs; range: 65–87 yrs) elderly women’s radiographs (T4–L5) were from two OVF population-based epidemiological studies conducted in Hong Kong (n = 200) and in Rome (n = 200). All radiographs were double read by one reader in Hong Kong and one reader in Rome, and consensus was achieved for each case. Radiological osteoporotic vertebral deformity (ROVD) classification included no ROVD (grade 0), and ROVDs with <20%, 20∼25%, ≥25%∼1/3, ≥1/3∼40%, ≥40%∼2/3, and ≥2/3 height loss (grade 1∼6) as well as endplate/cortex fracture (ECF). Spinal deformity index (SDI) was calculated with each vertebra assigned a score of 0, 0.5, 1, 1.5, 2, 2.5 and 3 for no ROVD or ROVDs grade 1∼6. Results: 77 (38.5%) Chinese subjects and 123 Italian subjects (61.5%) had ROVD, respectively (P < 0.0001). Hong Kong Chinese subjects had ECF in 52 (26%) cases involving 100 vertebrae, while Italian subjects had ECF in 93 (47%) cases involving 230 vertebrae. ROVDs in Italian subjects tended to be more severe (total and mean SDI: 454.5 and 3.71 for Italian, and 212 and 2.72 for Chinese, P < 0.05), more likely to be multiple (37% vs 19.5%) , more likely to have severe (26% vs 9.5%) and collapsed (17% vs 8%) grades . The slope of the relationship between age vs. SDI was steeper for the Italian subjects than for the Chinese subjects, suggesting ROVD severity developed faster for aging Italian subjects. A trend suggested earlier onset of ROVD among Italian. Conclusion: OVF in Chinese women tend to be less common, less severe and less likely to have multiple fractures. Together with less prevalent and less severe spinal degenerative changes in Chinese women, these factors may have contributed to the commonly reported lower prevalence of back pain among Chinese.

P153: Socio-Economic and Health-Related Characteristics Associated With Falls and Hip Fractures Among Brazilian Older Adults – An Analysis of the National Survey of Health

S. Câmara ^*1 , A. Cavalcante ² , Á. Maciel ¹ , and M. Mata ³

¹ Department of Physiotherapy, Federal University of Rio Grande do Norte, Natal, ² Faculty of Health Sciences of Trairi, Federal University of Rio Grande do Norte, Santa Cruz, ³ Health school, Federal University of Rio Grande do Norte, Natal, Brazil

Introduction: Epidemiological studies aiming at understanding how socio-economic and health-related characteristics associate with falls and hip fractures among older adults may help to plan health strategies to reduce the high burden of disability and elevated costs associated with them. This study aims to evaluate the characteristics associated with falls and fractures among a nationally representative sample of older adults from Brazil. Methods: The National Survey of Health, conducted by the Brazilian Institutes of Geographics in 2013, is a national household-based survey that collected information of Brazilian citizens across the country. Participants provided information about the occurrence of falls and hip fractures in the past 12 months. Non-fallers, fallers without fracture and fallers with fracture were compared in relation to socio-economic characteristics, chronic conditions, depression, distance and near-vision impairment, hearing impairment, and participation in social activities. Multinominal regression models were performed to test the variables that remain associated with the status of falls and fractures. Results: A total of 23,815 older adults participated: 21,986 were non-fallers (69.6y), 1,705 were fallers without fracture (71.9y) and 120 fallers with fracture (75.2y). Fallers with fractures present a higher proportion of women and non-white participants (70.8% and 58.3%) than the fallers without fracture (67.3% and 50.9%) and non-fallers (54.8% and 53.9%) (P < 0.01). Falls were associated with being illiterate (P < 0.01), not living with a spouse (P < 0.01), living in an urban area (P = 0.03). The results of the multivariate analysis showed that, compared with non-fallers, fallers without fracture present higher likelihood of being older (OR = 1.1, P < 0.01), having chronic conditions (OR = 1.4, P < 0.01) and depression (OR = 1.7, P < 0.01) and lower odds of being male (OR = 0.7, P < 0.01), living with a spouse (OR = 0.8, P < 0.01), and reporting no vision impairment (OR = 0.7, P < 0.01). Hip fracture remained associated with higher likelihood of being older (OR = 1.1, P < 0.01), having depression (OR = 2.9, P < 0.01) and lower likelihood of participating of social activities (OR = 0.2, P < 0.01). Conclusion: This study shows that socio-economic and health-related variables are associated with falls and hip fractures among Brazilian older adults. Preventive and rehabilitation strategies targeting falls and hip fractures in Brazil must consider those characteristics to achieve successful results.

P154: Cost of Osteoporosis-Related Hip Fractures in a Private Tertiary Hospital

A. J. Ho ^*1

¹ Orthopaedics, Chong Hua Hospital, Cebu City, Philippines

Introduction: Osteoporosis-related hip fractures, lead to great burden both for the patient and economy. Due to the paucity of burden of illness studies of osteoporosis in the Philippines, it is difficult to allocate healthcare resources appropriately for fracture prevention. Methods: Data from patients diagnosed with osteoporosis-related hip fractures from January 1, 2017, to December 31, 2019, were analyzed. The researcher recorded the patient’s demographic data, type of hip fracture, type of treatment, duration of hospitalization, and medical costs. Descriptive statistics, t-test, chi-squared test, ANOVA with Tukey HSD test and regression analysis were employed. Results: Among the 150 patients, 44.6% were within the 80-year-old and above age group and majority (76%) were females. The most common type of osteoporotic hip fracture involved the femoral neck (52.7%) and most of the patients underwent partial hip replacement (66%). Patients 80 and above age group, those sustaining an intertrochanteric fracture and those who were treated with internal fixation had a longer length of stay in the hospital. There was note of a parallel increase in the direct medical cost as the patients age group got older. It was found that femoral neck fracture had significantly higher implant costs while the other costs (hospitalization, surgery, laboratories, and medications) were observed to be comparable between the two types of fracture. Conclusion: The overall mean cost of osteoporosis-related hip fracture was 5227.78 USD. The implant used on average accounted for approximately 27% of the total direct medical costs. It was noted that 26% and 23% of the total cost was attributed to the cost of surgery and hospitalization, respectively. Medication costs accounted for 11% while laboratory costs comprised 13% of total costs.

P155: Quality Improvement Project on Trauma and Orthopaedic Junior Doctor Knowledge and Assessment/ Management of Common Peri/Post-Operative Complications

T. Richardson ^*1 , S. Naqvi ¹ , and S. Gordon ¹

¹ Trauma and Orthopaedics, Sandwell and West Birmingham NHS Trust, West Brom, UK

Introduction: Foundation doctors knowledge of common peri/post-operative complications can be hugely variable when commencing Trauma and Orthopaedic rotations. This can result in reduced awareness and confidence in the assessment and initial management of surgical complications. A quality improvement project was therefore designed with the following objectives: 1. To assess the confidence of foundation doctors on the assessment and management of common peri and post-operative complications on starting and finishing their T&O placement; 2. To offer regular orthogeriatric teaching on assessment and management of common peri and post-operative complications; 3. To review and produce a booklet on assessment and management of common peri and post-operative complications and deliver to all T&O foundation doctors and possibly expand to all surgical specialties; 4. To review if the above methods were successful in improving doctors’ knowledge of assessment and management of common peri and post-operative complications. Methods: PDSA cycle. Anonymous survey pre and post rotation sent out to all F1 and F2 doctors. This assessed their confidence before and after their rotation in seven different common complications. We also asked for feedback regarding how they felt their confidence would be improved (formal teaching, sim sessions, producing a guide, etc.). This was repeated over the course of the year covering three sets of four month rotations. Results: The QIP illustrated that foundation doctors improved confidence in managing complications with a combination of regular formal teaching, receiving a complications handbook/guide and through informal feedback on ward rounds. The audit illustrated areas where confidence was low and did not improve (wound healing) or the guide lacked information (diabetes management and COVID). Through improvements in teaching and the guide we were able to see increasing confidence levels throughout the subsequent cycles of the QIP. Conclusion: (1) F1 and F2 doctors often have low confidence when starting a T&O rotation in dealing with common peri/post-operative complications. (2) By offering formal teaching, producing a booklet and feedback and assessing F1s and F2s regularly during their rotation we were able to see an increase in confidence. (3) Further QIP cycles should be undertaken to further pursue ways of engaging and improving junior doctor confidence.

P156: Perspectives on Impact Exercises and Strength Training Among People With Osteoporosis

I. B. Rodrigues ^*1 , E. Wang ¹ , H. Keller ^1,2 , G. Heckman ^2,3 , and L. M. Giangregorio ^1,2

¹ Kinesiology and Health Sciences, University of Waterloo, ² Schlegel-University of Waterloo Research Institute for Aging, ³ Public Health and Health Systems, University of Waterloo, Waterloo, Canada

Introduction: Osteoporosis exercise guidelines recommend functional and balance training, progressive strength training, and weight-bearing or impact exercises. While the recommendations are recognized by the scientific community, translation of the guidelines into practice receives little attention. Before developing interventions to improve uptake of the guideline, we should explore perspectives on the recommendations. The aim of this study was to understand the perspectives of adults with osteoporosis on starting or continuing moderate or high impact exercise and strength training. Methods: We conducted one-on-one interviews with people ≥50 years with osteoporosis or low bone mass (T-score < −1) who were presently, previously, or not active. We recruited individuals nationally and internationally through our email distribution list, social media, and snowball sampling. Transcripts were transcribed verbatim and uploaded to Nvivo. We used inductive thematic analysis to analyze the data. Results: We interviewed 43 individuals (68±6.9 years); 19 people had prior fragility fractures. We identified 3 themes. Knowledge: Participants were aware that weightbearing and strength training were recommended to manage osteoporosis. Individuals had a basic understanding of strength training and those currently training used resistance bands, free weights, or body weight to perform single joint movements. There was limited insight on how to progress the exercise program, reach muscle fatigue, or incorporate sets and repetitions. Participants had limited knowledge of impact exercise and associated the term impact with jolting and bursting movements. Capability: All participants were willing to engage in moderate or high intensity strength training; however, they expressed a variety of views about doing moderate or high impact exercises. Those with prior injuries or fractures were less comfortable engaging in impact exercise. Exercise support: Participants reported several types of resources to support their involvement in moderate or high intensity training including videos, printed materials, and community classes led by exercise professionals with knowledge in osteoporosis. In addition, participants emphasized that ongoing support and accountability were needed to keep them motivated. Conclusion: Participants had a good understanding of the recommendations, but there is limited knowledge on how to maximize benefits. They also mentioned several types of patient-mediated tools and support systems to keep them motivated.

P157: Barriers and Enablers to Blue Book Recommended Management of Fall-Related Hip Fracture: A Qualitative Study to Understand Context in Low- and Middle-Income Countries in the Asia-Pacific Region

E. Armstrong ^*1,2 , X. Yin ³ , C. Pham ⁴ , P. Sa-ngasoongsong ⁵ , I. Tabu ⁶ , J. Jagnoor ⁷ , I. Cameron ⁸ , V. Sharma ⁹ , M. Yang ¹⁰ , J. Zhang ¹ , H. Razee ¹ , J. Close ^2,11 , I. Harris ^12,13 , M. Tian ^14,15 , and R. Ivers ¹

¹ School of Population Health, UNSW Sydney, Kensington, ² Falls Balance Injury Research Centre, NeuRA, Randwick, ³ Faculty of Medicine and Health, The George Institute for Global Health, Sydney, Australia, ⁴ Center for Injury Policy and Prevention Research, Hanoi University of Public Health, Hanoi, Viet Nam, ⁵ Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, ⁶ Department of Orthopaedics, University of the Philippines Manila-Philippine General Hospital, Manila, Philippines, ⁷ Injury Division, The George Institute for Global Health, New Delhi, India, ⁸ Kolling Institute of Medical Research, University of Sydney, Sydney, Australia, ⁹ Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India ¹⁰ Department of Orthopaedics and Traumatology, Beijing Jishuitan Hospital, Beijing, China ¹¹ Prince of Wales Clinical School, UNSW Sydney, Kensington ¹² South West Sydney Clinical School, UNSW, Sydney ¹³ Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia ¹⁴ Injury and Trauma, The George Institute for Global Health at Peking University Health Science Centre, Beijing, China ¹⁵ The George Institute for Global Health, UNSW Sydney, Kensington, Australia

Introduction: Fragility fractures are emerging as a major public health issue due to the changing demographics of global populations. High income countries (HICs) have prioritised initiatives to improve fragility fracture care knowing that high-quality care is effective, efficient and improves patient outcomes. Guidelines, quality standards and audits for hip fracture are common across HICs. Development of these is resource-intensive and their implementation is influenced by context-specific factors. Knowledge of local context is required to inform strategies for implementation. This study explores the delivery of hip fracture care in Low- and Middle-Income Countries in the Asia-Pacific region against a reference point of the British Blue Book to identify barriers and enablers to the provision of recommended hip fracture care. Methods: In-depth, semi-structured interviews based on Blue Book Standards were conducted between August 2019 and August 2020 with clinicians and administrators in five countries (China, India, Thailand, The Philippines and Vietnam). Interviews were conducted in the preferred language of the participant and translated into English, where required, for analysis. Deductive and inductive methods were adopted for analysis: the coding framework was modified through an iterative process until final themes agreed. Results: Thirty-five staff from eleven hospitals participated. Hospital or system level barriers to provision of recommended care include the absence of structured trauma transport systems and universal insurance systems, low clinical prioritisation, limited access to blood for surgery, and formal interdisciplinary communication methods. Patient level barriers include not knowing the consequences of a fall, fear of surgery, financial costs of treatment and family negotiations delaying decisions. Hospital or system level enablers include written protocols, networking with lower level hospitals, and clinical leadership. Patient level enablers include being medically well on arrival, knowledge of surgical benefits through social networks, and relatives as proxy staff. Conclusion: Clinicians and administrators face multi-level contextual barriers to the provision of recommended care: many barriers are outside their capacity to change. Context-specific solutions at the point of care, such as, locally agreed protocols and streamlined methods of referral and communication, may minimise in-hospital delays and financial costs, thus facilitating Blue Book recommended hip fracture care.

P158: Is the Swansea Hip Interrogation Fracture Tool Reliable When Used in Our Local Hospital Population?

T. Fleming ^{* 1,2} , N. Anwyll ² , C. Daly ¹ , J. Hinds ¹ , and G. Jenkins ¹

¹ Orthopaedics, ² Orthogeriatrics, Somerset NHS foundation Trust, Taunton, UK

Introduction: The Swansea Hip interrogation Fracture Tool (SHiFT) was suggested combining the Clinical Frailty score and Nottingham hip fracture scores, and then using this combined score to aid clinical decision making during COVID 19 pandemic. The tool suggested three groups with suggested treatment decisions; scores 2 to 8 have surgery within 36 hours, scores 9 to 12 have surgery potentially delayed up to 7 days, scores 12 plus to be non-operative management. Swansea hospital treats approximately 500 to 600 hip fractures annually. Musgrove Park Hospital treats approximately 450 hip fractures annually therefore the aim of your study was to assess the reliability of this tool in our local population. Methods: A retrospective review of patients admitted with a hip fracture between January 2018 and December 2019. The date of discharge, the date of death if applicable, the clinical frailty score and Nottingham hip score, and the SHiFT score were recorded. The original study assessed mortality at 4 months therefore similar local data was collected. The local results were compared to the original SHiFT outcomes. Results: The original SHiFT study had 124 patients with an annual mortality rate of 26%. Our study had 103 patients with mortality rate of 26%. Our SHiFT scores ranged from 2 to 16, 25.2% had a score between 2 and 8, 50.5% had a score between 9 and 12, and 24.3% had a score of 13 to 16. The original SHiFT study scores range from 6 to 15 with respective percentage in each group of 34%, 56%, 10%. In our study 3.8% of patients with score between 2 and 8 died within 4 months, 9.6% of patients with scores 9 to 12, and 36% with scores 13 to 16. The percentage of deaths at 4 months within the same groups in the original study was 2%, 34%, and 58%. Conclusion: Whilst we recognise that clinical decision-making regarding resource allocation is difficult especially during a pandemic, we would not recommend using a tool such as SHiFT as this was not a reliable tool. Whilst our local population had a higher percentage of frailer patients with comorbidity this did not translate into higher mortality. Therefore, using this tool would have resulted in numerous patients being triage for inappropriate treatment decisions. We recognise that the main limitation in this study as well as the original study is the small patient numbers.

P159: The Development of Chinese Hip Fracture Registry for Older Patients

X. Zhang ^*1 , M. Yang ² , J. Zhang ³ , P. Ye ^4,5 , and M. Tian ^1,4

¹ The George Institute for Global Health at Peking University Health Science Center, ² Department of Orthopaedic and Traumatology, Beijing Jishuitan Hospital, Beijing, China, ³ School of Population Health, Faculty of Medicine, University of New South Wales, ⁴ The George Institute for Global Health, University of New South Wales, Sydney, Australia, ⁵ National Centre for Non-communicable Disease Control and Prevention, Chinese Centre for Disease Control and Prevention, Beijing, China

Introduction: Hip fracture has become a major public health issue among older people globally. Many high-income countries have established national hip fracture registry to improve the quality of management. Despite a growing burden of hip fracture in China, a national registry is not yet existed. In this study, we aim to develop a Chinese hip fracture registry for older patients. Methods: The registry development follows three steps. Step 1, a three-round online Delphi process will be conducted to reach consensus on the key variables included in the Chinese hip fracture registry. We will use purposive sampling strategy to identify participants from diverse background. In round 1, consented participants will rate all potential variables from importance and feasibility domains, using 5-point Likert scale. Participants’ responses will be analyzed by boundary value calculation methods. In round 2, variables with mean score < 4.0 or agreement < 75%, together with newly added variables in round 1 will be rated using the same process as round 1. The Delphi process will be ceased until participants reach consensus on the selection of all variables. Step 2, an electronic-based registry will be developed, based on the findings in the step 1. The registry will then be pilot tested in six hospitals by prospectively enrolling older hip fracture patients for one month. The completion, accuracy of data and the user experience will be evaluated. Step 3, individual in-depth interviews or focus group interviews will be conducted from purposively selected participants, to identify the barriers and enablers of implementing the registry at a scale. Results: The development of Chinese hip fracture registry has been endorsed by the National Health commission. We have received the ethics approval from Beijing Jishuitan Hospital in June 2021, with the Delphi process to be started from July 2021. Conclusion: The Chinese hip fracture registry is expected to improve the quality of hip fracture management for older people via regular audit.

P160: Improving Peri-Operative Fasting Times and the Use of Nutritional Boosts in Trauma Patients

D. Bishop ^*1

¹ Trauma, OUH, Oxford, UK

Introduction: In 2018 data was collected on the fasting times for patients that supported the hypothesis that they were experiencing extended fasting around surgery. Mean fasting times for fluids pre-op was 12 hours and 54 minutes, food was 18 hours 36 minutes. Total mean fasting times for fluids was 19 hours 6 minutes, food was 25 hours 24 minutes. The results were presented at our fragility fracture meeting and the multidisciplinary group supported further work to reduce these. Methods: The audit initiated momentum for new pre-op fasting guidelines that coincided with the rollout of the neck of femur fracture PowerPlan for the Electronic Patient Records system, both of which advocate the use of high-calorie juice drinks as a nutritional boost pre-surgery. Additionally, an educational programme was created with the clinical education team to raise staff’s awareness around pre-op fasting, our recent audit results and introduced the newly developed guidelines. Repeat audit cycles were carried out and data was captured retrospectively. Data was collected from electronic and paper patient records, patient and staff conversation (where possible and appropriate) and nutritional folders/food charts. Paediatric and intensive care patients were excluded. Results: Since the 2018 audit and the changes implemented, 3 further audits cycles have been completed. There has been a gradual improvement in fasting times since then, most marked in the important area of fluid fasting time. The November 2020 cycle for all patients showed mean fasting time for fluids pre-op was 8 hours and 26, food was 15 hours 34 minutes. For total fasting times, the mean for fluids was 14 hours 42, food was 25 hours 30 minutes. This audit contained a larger percentage of outlying patients than any previous cycle and when trauma ward inpatients were looked at in isolation the timings were reduced on all fronts: fluid fasting pre-op was 6 hours and 18 minutes for these patients. Conclusion: Improvements in most aspects of pre-op fasting have been shown through developing the pre-op guidelines, the educational programme and the PowerPlan. Fasting times are often still longer than current guidelines (i.e., 2 hours for clear fluids and 6 hours for food) and reducing them further will be challenging given the largely unplanned nature of the surgery performed, and with potential changing of the list order due to incoming emergencies. We hope that the addition of a nutritional assistant to our team will help to improve things in the future.

P161: Impact of Socioeconomic Factors on Patient’s Adherence to Lifestyle Modifications Aimed at Reducing Future Fracture Risk in Geriatric Patients With Peri Trochanteric Fragility Fractures of the Hip

A. Kale ¹ , and J. Sharma ^*1

¹ Orthopaedics, Dr. DY Patil Medical college and hospital, Pune, India

Introduction: History of fracture is a well-documented risk factor for sustaining future falls and subsequent fractures in geriatric patients. Orthopaedic surgeons advocate various lifestyle modifications to reduce the risk of sustaining a recurrent fracture in this vulnerable group. However, patient adherence to the advised lifestyle modifications has not been documented in any previous studies. In our study, we aimed to evaluate patient compliance and adherence to the lifestyle modifications intended at reducing future fracture risk. Methods: 112 patients aged >65 years who were diagnosed as having peri trochanteric fragility fracture of the hip and were treated operatively for the same were included in this study. Upon discharge from the hospital, the patients were advised 10 lifestyle modifications to reduce recurrent fracture risk. A data collecting form which graded the adherence on a 20-point scale (2 points for each lifestyle modification) was prepared by the investigators. Upon the six monthly follow up visit, adherence was assessed on the 20 point scale and data was collected via the face-to-face interview method. Statistical analysis was accomplished by Chi-square test and logistic regression analysis. Results: Of the 112 subjects included in the study 58 (51.7%) were male and mean age was 75 ± 8 (65 – 92) years. The adherence to less than 4 recommendations (Score <8) was seen in 39.2%, adherence to 4 – 6 recommendations (Score between 8 and 12) was seen in 30.86%, adherence to 6 and 8 recommendations (Score between 12 and 16) was seen in 29.94% and adherence to 8 and 10 recommendations (Score between 16 and 20) was seen in 0% of participants. According to the regression analysis presence of adherence to less than 6 recommendations was related to low income level (OR = 0.298; 95% CI 0.132–0.666; P < 0.001) and lack of education and awareness. (OR = 2.329; 95% CI 1.114–4.859; P = 0.002). Conclusion: The rates of adherence to advised lifestyle modifications was generally found to be low. Compliance was particularly reduced in patients belonging to lower socioeconomic strata, which were less likely to be educated and had lower rates of income. The authors concluded that merely advising lifestyle modifications to reduce fracture risk was not enough to stop the menace of recurrent fragility fractures in this vulnerable population group. There is an urgent need to institute social security and public health measures to improve patient adherence, and to reduce future fracture risk in an ageing population.

P162: Variability in Hip Fracture Pain Management Protocols in Scotland: A National Survey

H. Garside ^*1 , A. MacLullich ^2,3 , and K. Ward ⁴

¹ University of Edinburgh, ² Usher Institute, University of Edinburgh, ³ Chair, ⁴ National Clinical Coordinator, Scottish Hip Fracture Audit, Edinburgh, UK

Introduction: Effective pain management in acute hip fracture is essential for multiple reasons including facilitating early mobilisation, reducing the risk of delirium, improving sleep, and quality of life. Yet there is little published evidence on what protocols are used in practice. There are around 7000 hip fractures in Scotland per year, and the National Health Service (government-funded single payer system) provides >99% of acute hip fracture care across 19 hospitals. Our aim was to study pain management protocols in current clinical use in Scotland. Methods: Pain management protocols from hospitals in Scotland providing acute hip fracture care were requested using the network Scottish Hip Fracture Audit (SHFA) team. We summarised information on analgesics, anti-emetics and laxatives, as well as protocol formats and other content. Results: Of the 19 requests one hospital was updating the protocol and so did not provide a current one, and three did not respond, giving 15 responses used for this analysis (79%). Paracetamol was used first line in all but one hospital, and 12/15 (80%) suggested a reduced dose for smaller or frailer patients. Half of hospitals used oxycodone as the first line regular and ‘as required’ opioid and 6/15 (40%) used morphine; dosing regimes varied among hospitals. Two hospitals used dihydrocodeine as the first line regular and ‘as required’ medication. 3 hospitals used oxycodone as the regular opioid in high risk patients indicated by low eGFR or signs of delirium and 3 hospitals used morphine in this patient group. 2 hospitals suggested alfentanil (subcutaneous or sublingual) for short-term cover of physiotherapy sessions. Only 6/15 (40%) of hospitals provided guidance on drugs to be used after strong opioids including at discharge. 12/15 (80%) of hospitals included advice for laxative prescribing in their protocol and half included advice for prescribing antiemetics. There was considerable variability in the formatting of protocols and the supporting information provided. Conclusion: We found that there was considerable variability in the management of pain in acute hip fracture in Scotland. This is surprising given that this is a single-payer system and that patient demographics are similar across hospitals. The findings suggest that more work is needed both to streamline prescribing practice based both on evidence and expert consensus. Gaps in the evidence informing practice need to be addressed with further studies.

P163: Peri-Prosthetic Femoral Fractures: A Review of the First Year of Data Collection From the National Hip Fracture Database

J. Evans ^*1,2 , D. Inman ^2,3 , and A. Johansen ^2,4

¹ Musculoskeletal Research Unit, University of Bristol, Bristol, ² National Hip Fracture Database, Royal College of Physicians, London, ³ Northumbria Specialist Emergency Care Hospital, Northumbria Healthcare NHS Foundation Trust, Cramlington, ⁴ Trauma Unit, University Hospital of Wales, Cardiff, UK

Introduction: The National Hip Fracture Database (NHFD) started collecting data on peri-prosthetic femoral fractures (PPFF) in England and Wales in December 2019. We reviewed the data from the first year of data collection to describe the patients being admitted with PPFF and the care they received according to established Key Performance Indicators (KPIs) used in hip fracture surgery. Methods: We performed a retrospective review of PPFF reported to NHFD between 1 January and 31 December 2020. Analyses consisted of the summary statistics used to generate the NHFD annual report. Of the KPIs used in hip fracture, summary data were available for PPFF on time to assessment by a geriatrician (KPI 1), time to theatre (if applicable) (KPI 2), and mobilisation the day after surgery (if applicable) (KPI 4). Results: There were 2,411 PPFF fractures around a hip or knee replacement reported out of a total of 2,606 PPFF and we focussed on this group of patients. Of the 171 hospitals who reported data to the NHFD, 135 reported at least one PPFF around a hip or knee replacement. The median number of fractures per hospital was 14 (IQR 8, 25, range 1 to 110). The median age of patients was 84 (range 60 to 104) and 1,604 (67%) patients were female. Of the 1,850 occasions a time to geriatrician review was documented, review within 72 hours was achieved on 89.2% of occasions. Of the 1,973 patients who underwent operative interventions, 546 patients went to theatre before the 36-hour target representing 28.4% of those with data. Of patients who had surgery 1,323 (67.4%) were mobilised the following day. Conclusion: In the first year collecting data on PPFF we can give an idea of the incidence of these potentially life changing injuries. Most hospitals admitted an average of over one case a month (pro-rata) with a wide range of up to 110 cases per year. Whilst geriatrician review with 72 hours was achieved in a high proportion of cases nationally, our data suggest fewer patients are mobilised the day after surgery. Notably, only 28.4% of patients who were managed operatively went to theatre within 36 hours of admission. With the demographic of patients sustaining these injuries being like those suffering hip fracture, common sense would suggest that patients would benefit from similar management. We provide the first insight into the incidence and management of these injuries and these data should serve as a starting point for ongoing quality improvement work, reporting of routine data and further research into this injury.

P164: Driving Up the Standard of Care: The Irish Hip Fracture Database 8 Years On

L. Brent ^*1 , E. Ahern, ² , and C. Hurson ³

¹ National Office of Clinical Audit, Royal College of Surgeons in Ireland, Dublin, ² Geriatric Department, Cork University Hospital, Cork, ³ Orthopaedics, St. Vincent's University Hospital, Dublin, Ireland

Introduction: Each year over 3,700 patients over the age of sixty were hospitalised with a hip fracture in Ireland. The recognition of the growing burden of fragility fractures on the health service needs to be factored into the future development of hospital services. The IHFD is a clinically led, web based audit of hip fracture casemix, care and outcomes. The National Office of Clinical Audit (NOCA) provides operational support and governance for the IHFD. All 16 eligible hospitals in the Republic of Ireland are now entering data. It is clinically supported by the Irish Gerontological Society (IGS) and the Irish Institute of Trauma and Orthopaedics (IITOS). The IHFD has been recording data since 2012 and has captured over 25,000 cases to date. Methods: Data is collected through the Hospital In-Patient Enquiry (HIPE) portal in collaboration with the Healthcare Pricing Office (HPO). The IHFD audit was based originally on the six standards of care as published by the British Orthopaedic Association and British Geriatric Society in the “Blue Book”, the Care of Patients With Fragility Fracture (2007), but in 2017 the IHFD published the Irish Hip Fracture Standards (IHFS), in 2018 these standards formed the basis of a Best Practice Tariff (BPT), that is, a payment of €1000 per case that meets the IHFS. In 2021 a new standard for early mobilization will become part of the BPT. Results: 33% of patients were admitted to an orthopaedic ward or went to theatre within four hours, 75% of patients received surgery within 48 hours, 3% of patients developed a pressure ulcer, 56% of patients received a nutritional risk assessment to identify risk of malnutrition, 82% of patients were seen by a geriatrician, IHFS 5: 91% of patients received a bone health assessment, 85% of patients received a specialist falls assessment, 78% of patients were mobilised by a physiotherapist on the day of or day after surgery, 28% of patients were discharged directly home. Median of length of stay: 11 days. Conclusion: The coverage has improved consistently year on year and 99% was achieved in 2020. There has been an improvement in all IHFS with a minor disimprovement in 2020 due to COVID. The focus of the audit going forward will be support the hospitals to recover from the impact of the COVID pandemic, to increase the number of patient care meeting the BPT, to support the hospitals to adopt a culture of quality improvement using the IHFD data and to develop a longer term outcome dataset.

P165: Hip Fracture Registries in Low and Middle Income Countries: A Scoping Review

R. Klappenbach ^*1 , B. Lartigue ¹ , M. Beauchamp ¹ , B. Boietti ² , L. Bosque ¹ , and E. Monteverde ¹

¹ Fundación Trauma, ² Hospital Italiano de Buenos Aires, Buenos Aires, Argentina

Introduction: Hip fracture (HF) presents a high burden of disease in older people, and HF registries have been associated with a decrease in mortality and morbidity in high-income countries. Other quality improvement programs and registries, such as those for trauma, have shown to be effective in low- and middle-income countries (LMICs), but the use of HF registries in these settings were not formally explored. Methods: A structured review was carried out in three databases (PubMed, Google Scholar and Global Index Medicus), in websites related with HF and in the references of the studies. Two investigators independently performed the study selection and data extraction. Studies mentioning or describing the use of individual patient records with the aim to improve the quality of care in older people with HF in PIMB were included. Results: 222 references were identified, of which 9 studies regarding 3 registries were finally included in the qualitative review. In Malaysia, a registry was implemented in 18 public hospitals at least between 2008 and 2010, including an annual report; the registry did not include patients' follow-up or functional scales. A private referral hospital in Argentina implemented a registry associated with its electronic medical record, with long-term follow-up and the use of functional scales, although it did not mention the use of quality-of-care indicators and reports. Mexico published an initial experience during 2018 of a registry from 4 centers which included 54 patients with a 30-day follow-up, with the aim to conduct future periodic reports with quality indicators. Conclusion: The experiences on the use of hip fractures registries in LMIC are scarce. The registries identified present weaknesses that limit their usefulness for the implementation of quality improvement programs in regional and national healthcare systems.

P166: Alliance for the Development of the Argentinian Hip Fracture Registry

M. Beauchamp ^*1 , B. Boietti ² , M. Saieg ³ , L. Bosque ¹ , B. Lartigue ¹ , R. Klappenbach ¹ , V. Gutierrez Maxwell ⁴ , J. Neira ⁴ , J. Castellini ⁵ , M. Diehl ⁶ , P. Rey ⁶ , J. Bello ⁷ , M. B. Zanchetta ⁸ , M. Drnovsek ⁹ , N. Schwartz ⁹ , J. Nemerovsky ² , M. Mirofsky ¹⁰ , V. Matassa ¹¹ , A. S. Abbate ¹² , M. S. Larroudé ¹³ , E. Giacoia ¹³ , C. Graf ¹⁴ , R. Quintana ¹⁴ , and E. Monteverde ¹

¹ Fundación Trauma, ² Sociedad Argentina de Gerontología y Geriatría, ³ Fundación Navarro Viola, ⁴ Academia Nacional de Medicina, ⁵ Asociación Argentina de Ortopedia y Traumatología, ⁶ Asociación Argentina de Osteología y Metabolismo Mineral, ⁷ Asociación Argentina de Salud Pública, ⁸ Fundación de Investigaciones Metabólicas, ⁹ Sociedad Argentina de Endocrinología y Metabolismo ¹⁰ Sociedad Argentina de Medicina ¹¹ Sociedad Argentina de Medicina Física y Rehabilitación ¹² Sociedad Argentina de Medicina Interna General ¹³ Sociedad Argentina de Osteoporosis ¹⁴ Sociedad Argentina de Reumatología, Buenos Aires, Argentina

Introduction: Hip fractures are one of the most important problems the elderly face, affecting approximately 1.6 million people per year worldwide, with a projection of 6.3 million for 2050. Although hip fracture registries (HFR) helped to improve clinical outcomes, process of care, and cost management in developed countries, they are scarcely replicated in low and middle income ones. Methods: Objective: To describe the development of the Argentinian HFR (RFC, for its acronym in Spanish). Setting: A three-partner alliance got established in 2020: Fundación Trauma (an academic NGO) as developer and administrator, Fundación Navarro Viola (a societal NGO) for technical and financial support, and the Argentinian Network for Hip Fracture in the Elderly (RAFCA) for scientific endorsement, the latter composed by 12 scientific societies devoted to hip fracture-related specialties. We started with a review of biomedical databases to identify the most renowned HFR in the world. Between October 2020 and June 2021, we conducted an iterative consensus process that involved 5 specialty-focused meetings and 9 general meetings with more than 20 specialists. This process included inclusion criteria definition, dataset proposals, development of an exclusive online platform with data security, definition of registry levels according to the heterogeneity of healthcare in Argentina, and definitions on the implementation plan and the sustainability strategy. Results: By June 2021, we were able to: [1] outline the package of 99 fields that include epidemiological, clinical and functional dimensions for the pre-admission, hospitalization, discharge and follow-up stages; [2] define 3 registry levels: basic (53 fields), intermediate (85 fields) and advanced (99 fields); [3] identify 21 indicators for performance evaluation and benchmarking, and [4] make a correlation scheme between the most used hip fracture classifications. Simultaneously, we launched a fundraising campaign to implement the RFC in 30 centers, having so far reached the funds for 16. Conclusion: The development of the Argentinian HFR was based on 4 pillars: representativeness and support, solid definitions from the start, committed teams, and stable funding. This was the result of the collaborative work between the three stakeholders. We believe this tool will contribute to the designing of evidence-based public policies to reduce morbidity and mortality, improve people's quality of life, and promote healthy aging.

P167: Using Medicare Claims Data to Measure Healthy Aging in Place After Hip Fracture

J. Falvey ^*1 , and J. Yang ²

¹ Physical Therapy and Rehabilitation Science, University of Maryland School of Medicine, ² Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, US

Introduction: Older hip fracture patients spend 47 more days each year homebound or in a healthcare facility than their healthy peers. These important aging-in-place outcomes may be worse for racially minoritized patients, who are more likely to reside in socioeconomically disadvantaged neighborhoods and have poorer surgical outcomes. However, little work has evaluated racial disparities in patient-centered outcomes. Because the number of hip fractures among minoritized patients is growing, there is a need to understand these differences. Methods: The study cohort included adults on Medicare plans with a claim for hip fracture (n = 79495) between 2010 and 2018, survived the hospital stay, and did not have a previous hip fracture within 12 months. We limited the cohort to patients who were community-dwelling before hospitalization. Our primary outcome was healthy days at home over 12 months after fracture. Healthy days at home accounts for time spent at home versus a facility (i.e. rehab center) and also low-quality days at home, such as those requiring emergency care or those where patients are homebound. Validation research suggests days at home is associated with functional status and quality of life. Healthy days at home was represented as a percentage of days alive to account for mortality differences. We calculated descriptive statistics for the cohort by race/ethnicity, which was categorized as Non-Hispanic White (92%), Black (4%), Hispanic (1%), Asian (1%), or other/multiple race (i.e. Native American; 2%). We used generalized linear models to evaluate racial differences, adjusting for surgical variables, demographics (i.e. age, sex), and pre-hospitalization multimorbidity (Elixhauser Index and dementia status). We also adjusted for the mean number of healthy days at home 6 months prior to the fracture. Results: In general, Black hip fracture survivors were more likely to be male, had greater multimorbidity, and had longer hospital stays. After adjustment, Black patients spent 157 healthy days at home after hip fracture (48% of time alive) compared to 178 days for White patients (55%), 181 days for Hispanic patients (53%), 191 days for Asian patients (56%), and 184 days for other race/ethnicity (56%). Conclusion: We identified significant racial disparities in the quantity and quality of aging in place after hip fracture for Black survivors. Engaging Black hip fracture survivors to identify unmet needs, and implementing interventions with input from patient stakeholders is a critical next step.

P168: Short- and Long-Term Mortality in Patients With Osteoporotic Hip Fractures

O. Zubach ¹ , and N. Grygorieva ^*2

¹ Community non-profit enterprise "Clinical Hospital of Emergency Medical Care", Lviv, ² Dmitry F. Chebotarev Institute of Gerontology of the NAMS of Ukraine, Kyiv, Ukraine

Introduction: Hip fractures (HFs) are most dangerous complication of systemic osteoporosis that has a significant influence on survival parameters in patients of older age. Aim: To study the indices of short- and long-term mortality and parameters of survival in patients with HFs. Methods: We performed a retrospective study and analyzed the data of 146 females and 82 males with HFs aged 50 years and older (mean age (Me [25Q–75Q]): 74.5 [64.7–80.8] years old) hospitalized in Clinical Hospital of Emergency Medical Care (Lviv) in 2005–2007. Life outcome data were collected three times (in 2015, 2016 and 2017) by the researcher using telephone contact with patients or their relatives. The analysis was performed depending on age, gender, type of fracture and treatment, the presence of concomitant diseases. Results: The average follow-up period was 121.3 [30.6–143.9] months (143.4 [133.4–150.0] months for surviving patients and 49.4 [10.2–120.3] months for deceased). Women accounted for 64 % of all subjects with HFs and were significantly older than men. The average age at the time of death for the deceased patients (81.2 [72.2–85.1] years) was significantly higher in females (82.0 [72.9–86.8]) compared to males (76, 8 [66.3–84.8] years; Z = 2.0; P = 0.04), although it did not differ from the indices of survivors at the end of the study (79.2 [72.8–89.4] years). Hospital mortality rates were 1.3%, 6-month, 1-, 5- and 10-year mortality, respectively, 11.8%, 18.4%, 36.8% and 48.2%. Mortality rate increased with age and was significantly higher (P = 0.004) in the patients older than 70 years compared to younger patients. It was also higher in men compared to women only in the age group of 80–89 years. Mortality rate was higher in non-hospitalized and non-operated patients with HFs. The survival rate was depended on type of surgical treatment (it was highest in patients after hip replacement), while there were no significant differences in mortality depending on the type of fracture. Conclusion: Survival rate in the patients with HFs did not differ depending on gender (except of men aged 80–89 years old), type of fracture, and was significantly lower in the patients older than 70 years compared with younger patients and in non-hospitalized and non-operated patients.

P170: Asia Pacific Fragility Fracture Alliance – Fragility Fracture Network Hip Fracture Registry Toolbox: A Resource to Support Registry Implementation

P. Mitchell ^*1 , H. Seymour ² , E. Ahern ³ , M. Costa ⁴ , J. Magaziner ⁵ , J.-K. Lee ⁶ , D.-C. D. Chan ⁷ , R. Blank ⁸ , and J. Close ⁹

¹ School of Medicine, University of Notre Dame, Sydney, ² Department of Geriatrics and Aged Care, Fiona Stanley Hospital, Murdoch, Australia, ³ Department of Geriatric Medicine, Cork University Hospital, County Cork, Ireland, ⁴ Nuffield Department of Orthopaedics, University of Oxford, Oxford, UK, ⁵ University of Maryland School of Medicine, University of Maryland, Baltimore, USA, ⁶ Beacon Hospital, Petaling Jaya, Malaysia, ⁷ Superintendent Office, National University Hospital Hsin-Chu Branch, Hsinchu, Taiwan, Province of China, ⁸ The Garvan Institute of Medical Research, ⁹ Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney, Australia

Introduction: Hip fracture registries provide a mechanism to benchmark care provided by hospitals against clinical standards. As of May 2021, registries have been established in approximately one tenth of countries worldwide. A hip fracture registry toolbox is intended to provide practical tools to support registry development. Methods: The toolbox has been developed as a collaboration between the Asia Pacific Fragility Fracture Alliance (APFFA) Hip Fracture Registry Working Group and the Fragility Fracture Network (FFN) Hip Fracture Audit Special Interest Group. Results: The toolbox summarises essential components of national quality improvement programmes for hip fracture care. This features best practice clinical standards, including quality indicators (e.g. measures relating to pain assessment, time to surgery, early mobilisation, secondary fracture prevention and multidisciplinary management). Hip fracture registries provide the technical infrastructure for hospital teams to benchmark the care they provide against quality indicators. The toolbox also focuses on practical aspects of registry establishment including clinical leadership and engagement, getting buy-in from diverse stakeholders, building the case for change, registry planning and funding, piloting a registry, governance and ethics considerations, and a minimum common data set and data dictionary. A summary of the extensive literature on multidisciplinary care of hip fracture patients is provided, in addition to detailed case studies of national registries in Australia and New Zealand, Spain and the United Kingdom. A series of short interviews published on YouTube complement the toolbox with experience from leaders of well-established registries. Conclusion: The APFFA-FFN hip fracture registry toolbox provides a distillation of the global experience to date in establishing national registries. The toolbox is free for download from www.apfracturealliance.org/HFR-toolbox/ and is intended to support colleagues throughout the world who would like to establish a registry in their country.

P172: Hip Fracture Incidence – Using the National Hip Fracture Database (NHFD) to Examine Trends in Women and Men in the UK

A. Johansen ^*1,2 , B. Edwards ¹ , and D. Inman ^2,3

¹ Trauma Unit, University Hospital of Wales, Cardiff, ² National Hip Fracture Database, Royal College of Physicians, London, ³ Trauma and Orthopaedics, Northumbria Specialist Emergency Care Hospital, Cramlington, UK

Introduction: Hip fractures are well recognised as predominantly affecting those in the oldest age groups; the age groups which are growing most rapidly with recent demographic trends around the world. We set out to examine recent trends in total numbers, and the incidence of hip fractures among women and men in England, Wales and Northern Ireland; using data recorded by the National Hip Fracture Database for all over-60 year old people presenting with this injury in these countries. Methods: We analysed National Hip Fracture Database data on all over-60 year old people who presented with hip fracture in England, Wales and Northern Ireland in the calendar years 2012 and 2018, and compared these with Office of National Statistics figures for the total population size of these three countries over the same time period. Results: Between 2012 and 2018, the combined over-60 year old population of these countries increased by 18.5%. The number of women in this age range increased by 6.25 million (24.6%), but the number of men by 2.83 million (13.3%). In contrast, NHFD data showed that the total number of over-60 year olds presenting with hip fracture had only increased by 7.1%. This would suggest the age-specific hip fracture incidence to have fallen. However, we found very different pictures in the two sexes. Hip fracture incidence in over-60 year old women fell by 17%; from 6.5 to 5.3 per 1,000 per year (P < 0.001), which contrasts with a 7% rise from 2.7 to 2.9 per 1,000 per year in men (P < 0.001). In 2012 a total of 45,817 women and 16, 361 men sustained a hip fracture; with higher figures of 47,002 and 19,572 in 2018 that equated with increases of 2.6% and 19.6%, respectively. Conclusion: The proportion of all hip fractures affecting men rose from 26.3% in 2012 to 29.4% in 2018, demonstrating the need for greater focus on the prevention and treatment of hip fractures in men. Improving public awareness of the impact of osteoporosis in women appears to have contributed to the very different temporal trend in hip fracture numbers we have shown in the two sexes. This is a public health triumph, but suggests that greater attention should be paid to ensuring that men benefit from similar improvements; both in hip fracture prevention and in the care they receive following this injury.

P173: Trabecular Bone Score (TBS) as a Predictor of Major Osteoporotic Fracture in Postmenopausal Women: The 1st Study in Thailand

T. Amphansap ^*1 , and A. Therdyothin ¹

¹ Orthopaedic, Police General Hospital, Bangkok, Thailand

Introduction: Osteoporosis is a disease with diminished bone strength, a parameter influenced by a reduction in bone mass, captured by bone mineral density, and decreased bone quality, which was suggested to be measured by trabecular bone score (TBS). Lower trabecular bone score was reported to be associated with fracture risk in Caucasians, but studies in Asian population are scarce. By comparing postmenopausal women with and without major osteoporotic fracture (MOF), our study aims to determine whether TBS can predict fracture risk. Methods: We retrospectively recruit all postmenopausal women sent for dual-energy X-ray absorptiometry (DXA). The hospital online database and radiographs were reviewed to collect information on underlying disease, medication, previous fracture, bone mineral density and trabecular bone score. Patients with anti-osteoporotic medication use, skeletal malignancy, fracture from high-energy trauma, and with uninterpretable DXA images were excluded. Results: A total of 407 Thai postmenopausal women were enrolled, dividing into 292 women without fractures and 115 women with major osteoporotic fractures. The fracture group was older (73.36 ± 9.95 vs 66.00 ± 8.58, P < 0.001) and had lower serum 25(OH)D level (23.28 ± 9.09 vs 26.44 ± 9.20, P = 0.023). The mean TBS was lower in the fracture group, compared to the non-fracture group (1.244 ± 0.101 vs 1.272 ± 0.099, P = 0.011). Subgroup analysis resulted in significantly lower TBS in spine fracture, but not other sites of fracture. The odd ratio of fracture was 1.355 (P = 0.013) for a decrease in 1 SD of TBS. Conclusion: TBS was significantly lower in postmenopausal women with fractures with an odd ratio of 1.355 (P = 0.013) per SD decrease in TBS. Categorizing by fracture sites, TBS was only found to be significantly lower in the lumbar spine despite similar LS BMD.

P174: Effect of Covid-19 on Fragility Fracture Admission in a Tertiary Teaching Hospital in Malaysia

M. H. Cheah ^*1 , P. S. M. Lai ² , H. M. Khor ¹ , C. S. K. Chandrasekaran ³ , S. S. Jagdis Singh ³ , Y. K. Adnan ³ , M. R. Draman Yusof ³ , and T. Ong ¹

¹ Department of Medicine, ² Department of Primary Care Medicine, ³ Department of Orthopaedic Surgery, University of Malaya, Kuala Lumpur, Malaysia

Introduction: COVID-19 has led to a change in the health-seeking behaviour and the delivery of healthcare. Globally, fragility fracture admissions have reduced by 0–54% depending on location. When Malaysia implemented the third movement control order on 3 May 2021 in response to increasing COVID-19 cases, the number of orthopaedic beds in the University Malaya Medical Centre was reduced from over a hundred to twenty-eight. To date, the impact of COVID-19 on fragility fracture admission in Malaysia is unknown. This study aims to investigate the relationship between COVID-19 cases and fragility fracture admissions to a tertiary hospital in Malaysia. Methods: This retrospective study was conducted from April to June 2021 in the University Malaya Medical Centre. The patients admitted to the University Malaya Medical Centre with fragility fractures between April and June 2021 were identified and compared to the corresponding periods in 2018. Patients <50 years old and those who had fractures due to cancer were excluded. The relationship between the total number of COVID-19 cases per week and weekly fragility fractures admissions were determined. Results: A total of 406,479 COVID-19 cases were reported over 3 months (April, n = 63,213; May, n = 163,644; June, n = 179,622). Fifty-five patients [mean age (78.9±8.6), female (44/55,80%), hip fractures (36/55,65.5%)] were admitted in April-June 2021, which was a 35.3% reduction when compared to the same period in 2018 [n = 85, mean age (75.1±9.9), female (62/85,72.9%), hip fractures (53/85,62.4%)], although no significant difference was found between the baseline characteristics. However, both fragility fracture and hip fracture admissions were found to be negatively correlated (r = -0.76 and r = -0.75) with the COVID-19 cases (P < 0.01). Twelve (12/51,23.5%) patients admitted in 2021 due to post-fall fragility fractures presented to the hospital more than a day after their injury. The proportion of patients with delayed presentation (>1 day post-fall) increased over the study period (April = 5/26, 19.2%; May = 3/13, 23.1%; June = 4/12, 33.3%). Conclusion: There was a reduction in fragility fracture admissions during the COVID outbreak in Malaysia. There might be a rebound in cases after the COVID crisis is over, reorganising medical services may be warranted to ensure effective fracture care delivery.

P176: Telemedicine in Patients With Fragility Fractures in the COVID-19 Era

A. Capdevila-Reniu ^*1 , J. M. Santiago ² , T. Casanova ³ , L. Cuadra ⁴ , E. Sopena ⁵ , A. Llopis ⁶ , A. Ivanov ⁷ , and J. M. Cancio ⁸

¹ Hospital Clinic, Barcelona, ² Hospital Sociosanitario de l´Hospitalet. Barcelona, Hospitalet de Llobregat, ³ Hospital Moisès Broggi, Sant Joan Despí, ⁴ Consorci Sanitari de Terrassa, Terrassa ⁵ Hospital Sociosanitario Francoli, Tarragona, ⁶ Hospital Sant Jaume. Consorcio Sanitario del Maresme, Mataró, ⁷ Hospital Sant Antoni Abad. Consorcio Sanitario Alt Penedés Garraf, Vilanova i la Geltrú, ⁸ Centro Sociosanitario El Carme., Badalona, Spain

Introduction: The covid19 pandemic has forced the health system to restructure to prevent contagion of our patients. In this context, the members of the Orthogeriatric Group of the Catalan Society of Geriatrics and Gerontology (SCGiG) created a document that collected all the considerations to take into account during the pandemic, based on the current guides and scientific societies, in order to perform a correct follow-up, enhance adherence and prevent future falls. Methods: A bibliographic review was performed, defining the key points in the care of the fractured patient through telemedicine (document is available at http://scgig.cat/docs/gt-orto_covid.pdf). Results: During hospital admission, antiosteoporotic treatment should be started, evaluating indications with the patient and family, to ensure adherence. Diet intake of calcium and vitamin D will be assessed. Discharge report includes evaluation of treatment and monitoring plan, to be useful for liaison nurse, rehabilitator and general practitioner. Six-monthly follow up is recommended for patients with comorbidities, polypharmacy, confusion, fall-risk, or parenteral anti-osteoporotic treatment. With denosumab or teriparatide, annual laboratory tests are recommended, with GFR <20, every six months, at home if possible. Bisphosphonates can be followed by the GP. Zoledronate is not recommended due to delayed administration after surgery, and possibility of transient flu-like simptoms. In the telematic follow-up visit, in patients undergoing zoledronic acid treatment, the new dose can be delayed for 6–12 months, without risk. Consider sequential treatment. Denosumab treatment cannot be delayed, so the patient and family will be trained in self-administration. Support materials from laboratories will be useful to patient and caregivers. Conclusion: Telemedicine is a good strategy for a follow-up, to avoid hospital contact, and starts on hospital admission. Patient and caregivers need access to new technologies and able to understand medical instructions.