Elsevier

The Lancet

Volume 353, Issue 9156, 13 March 1999, Pages 878-882
The Lancet

Articles
Mortality after all major types of osteoporotic fracture in men and women: an observational study

https://doi.org/10.1016/S0140-6736(98)09075-8Get rights and content

Summary

Background

Mortality increases after hip fractures in women and more so in men. Little is known, however, about mortality after other fractures. We investigated the mortality associated with all fracture types in elderly women and men.

Methods

We did a 5-year prospective cohort study in the semi-urban city of Dubbo, Australia, of all residents aged 60 years and older (2413 women and 1898 men). Low-trauma osteoporotic fractures that occurred between 1989 and 1994, confirmed by radiography and personal interview, were classified as proximal femur, vertebral, and groupings of other major and minor fractures. We calculated standardised mortality rates from death certificates for people with fractures compared with the Dubbo population.

Findings

356 women and 137 men had low-trauma fractures. In women and men, mortality was increased in the first year after all major fractures. In women, agestandardised mortality ratios were 2·18 (95% CI 2·03–2·32) for proximal femur, 1·66 (1·51–1·80) for vertebral, 1·92 (1·70–2·14) for other major, and 0·75 (0·66–0·84) for minor fractures. In men, these ratios were 3·17 (2·90–3·44) for proximal femur, 2·38 (2·17–2·59) for vertebral, 2·22 (1·91–2·52) for other major, and 1·45 (1·25–1·65) for minor fractures. There were excess deaths (excluding minor fractures in women) in all age-groups.

Interpretation

All major fractures were associated with increased mortality, especially in men. The loss of potential years of life in the younger age-group shows that preventative strategies for fracture should not focus on older patients at the expense of younger women and of men.

Introduction

Although osteoporosis and related fractures are wellrecognised public-health concerns, their impact on mortality remains unclear. Increased mortality after hip fracture is generally accepted, but there are few data on the outcomes of other fracture types. Excess mortality varies after hip fracture, with 12-month rates ranging from 12% to 35%.1 The variation in these mortality estimates may relate to differences in demography, age of people studied, study size, and completeness and length of follow-up. Most excess mortality occurs within the first 3–12 months after fracture,2, 3, 4, 5 and increases with age.5, 6, 7, 8, 9, 10, 11

In women, low bone-mineral density has been associated with increased mortality independent of fracture.12, 13 At least some of the fracture-mortality association may, therefore, reflect the underlying health of the individual. Although comorbid health status has been associated with mortality after hip fracture in most studies,3, 5, 6, 7, 14, 15, 16, 17, 18, 19 this finding has not been universal.20

If osteoporosis is independently associated with mortality, increased mortality could be associated with other types of osteoporotic fractures. In one populationbased study, women with vertebral fractures had increased 5-year mortality.21 These were clinically diagnosed vertebral fractures that may represent only a third of all vertebral deformities. By contrast, the survival of women with forearm fractures,21, 22, 23 foot, or ankle fractures23 has been reported to be no different from that of the general community.

In men, several studies have investigated mortality after hip fracture but not other fracture types. Direct comparisons of results when possible have shown that survival seems to be worse in men than in women.3, 4, 5, 6, 7, 9, 10, 17, 24

We investigated mortality associated with all osteoporotic fractures in an elderly community cohort.

Section snippets

Patients

Dubbo is a semi-urban city 400 km northwest of Sydney, Australia. The population is about 32 000, of which 98·6% of people are white. The community is stable with its own centralised health services, and is representative of the Australian population.25

The Dubbo Osteoporosis Epidemiology Study is a longitudinal epidemiological study assessing risk factors for osteoporosis and fractures, which started in July, 1989. As part of that study, all radiography reports from the whole Dubbo population

Results

Between 1989 and 1994, there were 356 low-trauma fractures in women and 137 in men during 12 056 personyears and 9483 person-years of observation, respectively. The overall fracture incidence (per 1000 person-years) was 29·5 for women and 14·4 for men. In the two sexes, fracture rates increased with age, with an exponential increase for proximal femur and vertebral fractures. The increase for other major fractures was gradual, whereas incidence of minor fractures was generally constant. Among

Discussion

In an elderly population, we found that fracture patients had a higher mortality than did the general population, especially those with hip fractures. Men in all major fracture groups had consistently higher standardised mortality ratios (2·2–3·2) than women (1·7–2·2).

The attributable risk of mortality was higher in the 60–69-year age-group than in the 80-years-or-older agegroup because of larger numbers. It was, therefore, not surprising to find a large number of excess deaths and strikingly

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