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Hip geometry to predict femoral neck fracture: Only neck width has significant association
APME-371; No. of Pages 7 apollo medicine xxx (2016) xxx–xxx
Available online at www.sciencedirect.com
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Research Article
Hip geometry to predict femoral neck fracture: Only neck width has significant association§ Jonny Karunia Fajar a,*, Rusydi Rusydi b, Safrizal Rahman c, Armia Indra Nur Alam c, Azharuddin Azharuddin c a
Medical Research Unit, School of Medicine, University of Syiah Kuala, Banda Aceh 23111, Indonesia Resident of General Surgery, School of Medicine, University of Syiah Kuala, Banda Aceh, Indonesia c Department of Orthopedic and Traumatology, School of Medicine, University of Syiah Kuala, Dr. Zainoel Abidin Teaching Hospital, Banda Aceh, Indonesia b
article info
abstract
Article history:
Background: Efficacy of the use of hip geometry to predict femoral neck fracture is contro-
Received 14 May 2016
versial and it is influenced by the particular race. Studies on the use of hip geometry in
Accepted 27 May 2016
Aceh's population have never been done.
Available online xxx
Objectives: To determine the association of hip geometry with femoral neck fracture in
Keywords:
Methods: This study was an observational analysis. The design of this study was cross-
Femoral neck fracture
sectional. The study was conducted in Dr. Zainoel Abidin Teaching Hospital from May to
Hip geometry
August 2013. Hip geometry measurements were done, such as the following: hip axis length
elderly women in Dr. Zainoel Abidin Teaching Hospital.
Hip axis length
(HAL), femoral neck axis length (FNAL), femoral neck angle (FNA), and neck width (NW).
Femoral neck angle
Statistical analysis used was logistic regression test.
Neck width
Results: A total of 32 patients with femoral neck fractures and 32 control patients were followed in this study. The average value of hip geometry measurements in femoral neck fracture was HAL = 90.2 8.6, FNAL = 77.2 7.3, FNA = 131.7 6.2, NW = 32.3 3.4; and in nonfemoral neck fracture, it was HAL = 88.4 9.4, FNAL = 76.2 7.9, FNA = 131.5 7.3, NW = 29.8 3.3. Measurement HAL, FNAL, and FNA did not have a significant association with the incidence of femoral neck fracture (P > 0.05). However, NW measurement had a significant association with the incidence of femoral neck fracture (P < 0.05). Conclusion: Only NW measurement had a significant association with femoral neck fracture in older women in Dr. Zainoel Abidin Teaching Hospital. # 2016 Indraprastha Medical Corporation Ltd. All rights reserved.
§ This paper was presented in the 6th Annual Basic Science International Conference – University of Brawijaya 2016, Malang, Indonesia, on March 3rd, 2016. * Corresponding author. Tel.: +62 081235522287; fax: +62 0651 7551843. E-mail address: [email protected] (J.K. Fajar). http://dx.doi.org/10.1016/j.apme.2016.05.005 0976-0016/# 2016 Indraprastha Medical Corporation Ltd. All rights reserved.
Please cite this article in press as: Fajar JK, et al. Hip geometry to predict femoral neck fracture: Only neck width has significant association, Apollo Med. (2016), http://dx.doi.org/10.1016/j.apme.2016.05.005
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1.
Introduction
Fracture is a serious health problem. Annual direct care expenditures for fractures is about 1 trillion dollars in the United Kingdom (UK) and indirect costs (e.g., lost productivity for patients and caregivers) likely add billions of dollars to this figure.1 Fracture is a major cause of mortality and morbidity in the elderly.2 Fracture in the elderly is associated with decreased quality of life so that even minimal trauma can cause serious repercussions. There are three regions that are often affected by fractures in osteoporotic patients, i.e.: femoral neck, spine, and distal radius.3 The incidence of femoral neck fractures was 957.3 cases per 100,000 female and 414.4 cases per 100,000 United States (US) male population in 1986–2005,4 400 cases per 100,000 US population per year in 2010,5 and less than 200 per 100,000 Indonesian women per year in 2012.6 The incidence of femoral neck fractures was more common in postmenopause than premenopause women7 or in age ≥64 years.4 A study regarding femoral neck fractures has not been done in Aceh. Demographic data regarding the incidence of fractures around the World estimated that there would be an increase of femoral neck fractures incidence from about 1.7 million in 1990 to 6 million cases in 2050.8 Although the incidence of femoral neck fractures is often caused by trauma, these fractures also have a close association with osteoporosis.9 Osteoporosis is defined as low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk or bone mineral density (BMD) that is 2.5 standard deviations (SDs) or more below the young adult mean value.10 Hip geometry and BMD have been associated as a predilection of femoral neck fractures incidence.11 BMD is a marker of bone strength measurement. However, BMD does not fully reflect femoral neck fractures. Lewicki and Borges12 conducted a clinical study regarding femoral neck fractures using BMD. The results showed that the incidence of osteoporosis was only 40–50% of all patients with femoral neck fractures. This indicated that BMD reflected only partially. This is possible because bone strength is determined by several factors, including BMD, bone architecture (hip geometry), microarchitecture, matrix components, tissue mineral density, and bone damage.13 Hip geometry is the examination of bone strength based on the measurement of proximal femur geometry. Hip geometry measurement includes hip axis length (HAL) – the distance from pelvic rim to outer margin of greater trochanter along neck axis, femoral neck axis length (FNAL) – distance from user-defined center of femoral head to intersection of neck and shaft axes, femoral neck angle (FNA) – angle between derived axes of neck and shaft, and neck width (NW) – the width of the femoral neck.13 The results of hip geometry measurement are thought to be different for each tribe. Several studies have reported differences of hip geometry. Nakamura et al.14 reported hip geometry differences of Japanese (FNAL: 4.4 cm, NW: 0.57 cm, FNA: 1280) and American population (FNAL: 5.6 cm, NW: 0.99 cm, FNA; 1300), Theobald et al.15 reported hip geometry differences of the white and the black of America population where the black population has NW and
FNAL 25% lower than whites; Im and Lim16 reported hip geometry differences of Korean population; Nelson et al.17 reported hip geometry differences of African (FNAL: 4.74 cm, FNA: 130.10, NW: 0.94 cm), Mexican (FNAL: 4.64 cm, FNA: 131.10, NW; 0, 91 cm), and American population (FNAL: 4.62 cm, FNA: 131.10, NW; 0.92 cm), and LaCroix et al.18 reported hip geometry differences of American population. The use of hip geometry possible will give better results regarding femoral neck fractures. In addition, the study regarding hip geometry in Aceh population has never been done. Therefore, it is necessary to study regarding the association of hip geometry with the risk of femoral neck fractures in older women in Dr. Zainoel Abidin Teaching Hospital.
2.
Methods
2.1.
Study designs and participants
This study was a cross-sectional study conducted in Clinic of Orthopaedic and Radiology Installation in Dr. Zainoel Abidin Teaching Hospital from May 2013 to August 2013. The target population was all elderly women with femoral neck fractures (358 patients – updated 5 March 2013) treated in Dr. Zainoel Abidin Teaching Hospital. Inclusion criteria for this study were as follows: (1) suffered femoral neck fractures, (2) women aged over 45 years, (3) got inadequate trauma, (4) had Singh index less than 3, and (5) postmenopause women. The exclusion criteria in this study were as follows: (1) not willing to be the subject of study, both orally and written, (2) had multitrauma with high energy, (3) long bed rest, and (4) young people with osteoporosis caused by various diseases. A simple, random sampling method was used to select 358 population-representative patients. The sample of this study was 32 patients and 32 controls as the minimum sample size. Ethical approval was obtained from The Ethical Clearance Committee of School of Medicine, Syiah Kuala University, Banda Aceh, Indonesia. All patients were given explanation about the purpose, risks, and benefits, and written informed consent of study prior to the examination was obtained. Patients were informed that they could terminate the study at any time. Patients in this study were voluntary and patients received no incentive.
2.2.
Hip imaging and hip structural analysis
Hip imaging, including X-ray and CT scan, was conducted in Radiology Installation in Dr. Zainoel Abidin Teaching Hospital. Radiology imaging was interpreted by radiologists to determine femoral neck fracture and Singh index. Hip structural analysis (HSA) was conducted in Clinic of Orthopaedic in Dr. Zainoel Abidin Teaching Hospital. X-ray imaging was analyzed for HSA manually using a ruler. HSA in this study included HAL, FNAL, FNA, and NW measurements. The sketch of hip geometry measurement was described in Fig. 1.
2.3.
Study variables
1. Femoral neck fracture Femoral neck fracture is the fracture in femoral neck.9 Ordinal scale was used to assess this variable. These
Please cite this article in press as: Fajar JK, et al. Hip geometry to predict femoral neck fracture: Only neck width has significant association, Apollo Med. (2016), http://dx.doi.org/10.1016/j.apme.2016.05.005
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Fig. 1 – The scheme of hip geometry measurement.33 HAL, distance from pelvic rim to outer margin of greater trochanter along neck axis (A–C). FNAL, distance from user-defined center of femoral head to intersection of neck and shaft axes (B–C). FNA, angle between derived axes of neck and shaft (H). NW, the width of the femoral neck (F–G).13
2.
3.
4.
5.
variable measurement results were fracture and nonfracture. Hip X-ray and CT scan were used to assess this variable. Hip axis length (HAL) HAL is the distance from pelvic rim to outer margin of greater trochanter along neck axis.13 Ratio scale was used to assess this variable. These variable measurement results were numbers. Femoral neck axis length (FNAL) FNAL is distance from user-defined center of femoral head to intersection of neck and shaft axes.13 Ratio scale was used to assess this variable. These variable measurement results were numbers. Femoral neck angle (FNA) FNA is the angle between derived axes of neck and shaft.13 Ratio scale was used to assess this variable. These variable measurement results were numbers. Neck width (NW) NW is the width of the femoral neck.13 Ratio scale was used to assess this variable. These variable measurement results were numbers.
2.4.
Statistical analysis
Data were analyzed using univariate and bivariate analysis. Data regarding the relationship of femoral neck fractures with hip geometry were analyzed using bivariate analysis. Bivariate analysis used to assess these variables was logistic regression test using SPSS software. P < 0.05 was considered significant statistically.19
3.
Results
A total of 32 of 385 femoral neck fracture patients were selected for the study using random numbers. Of these, 13 patients had died. Therefore, the selection was continued to get 13 patients more. After getting 32 femoral neck fracture patients, five patients were excluded because they had Singh index four (one patient), had long bed rest (two patients), and got trauma with
high energy (two patients). The selection was continued to get five patients more. Controls were obtained from nonfracture patients in Dr. Zainoel Abidin Teaching Hospital. A total of 32 femoral neck fracture patients and 32 controls were recruited for the study. Participants of the study were 50– 89 years old; of these, 26.6% (17 participants) were 45–54 years old, 23.4% (15 participants) were 55–64 years old, and 50% (32 participants) were more than 64 years old. Table 1 summarizes study characteristics of 64 participants in the study. The average numbers of hip geometry (HAL, FNAL, FNA, and NW) measurement in patients with femoral neck fracture were 90.2 8.6 mm; 77.2 7.3 mm; 131.7 6.28; 32.3 3.4 mm, respectively, while the average numbers of hip geometry measurement in controls group were 88.4 9.4 mm; 76.2 7.9 mm; 131.5 7.38; 29.8 3.3 mm, respectively. In age group, the average numbers of hip geometry measurement of age group I (45–54 years old) were 90.0 10.9 mm; 77.6 9.0 mm; 132.7 7.98; 30.5 4.4 mm; for age group II (55–64 years old) were 90.8 6.6 mm; 77.6 6.3 mm; 132.1 7.28; 30.6 2.7 mm, and for age group III (>64 years old) were 88.2 8.6 mm; 75.8 7.4 mm; 130.8 5.98; 31.6 3.3 mm, respectively. Table 2 summarized the average numbers of hip geometry measurements in various groups. The study found that not all hip geometry parameters correlated with femoral neck fracture. This study found that there was a significant positive correlation between NW and the risk of femoral neck fracture (OR95%CI = 1.311 [1.055–1.630] P = 0.015) (Table 3), while no association was found between risk of femoral neck fracture and other parameters, i.e.: HAL (OR95%CI = 1.050 [0.847–1.302] P = 0.655), FNAL (OR95% CI = 0.989 [0.899–1.089] P = 0.828), FNA (OR95%CI = 0.915 [0.721–1.163] P = 0.468), and age group (OR95%CI = 1.872 [0.941–3.723] P = 0.074). Table 3 summarized the correlation of the risk of femoral neck fracture and other parameters.
4.
Discussion
Femoral neck fractures are a serious health problem and often occur in older women. Hip geometry is an examination of bone strength based on the measurement of the proximal femur
Please cite this article in press as: Fajar JK, et al. Hip geometry to predict femoral neck fracture: Only neck width has significant association, Apollo Med. (2016), http://dx.doi.org/10.1016/j.apme.2016.05.005
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Table 1 – Hip geometry measurements in the study. Femoral neck fracture patients Study ID no.
Controls
Age
HAL
FNAL
FNA
NW
Study ID no.
Age
HAL
FNAL
FNA
NW
54 77 89 54 75 52 66 65 72 73 71 83 66 54 80 71 75 74 64 60 72 84 61 60 68 66 70 74 52 85 54 62
96 83 88 90 101 82 90 87 90 86 88 82 96 95 80 88 92 74 90 86 85 90 90 78 87 110 90 100 112 94 100 85
83 73 73 80 85 68 76 78 77 77 74 69 84 88 65 74 80 66 76 75 76 80 76 65 72 90 80 84 96 77 85 70
129 122 129 130 126 135 135 120 138 134 128 134 130 124 130 130 128 124 135 120 132 132 135 128 140 138 132 140 148 135 134 140
34 35 35 35 33 26 30 35 34 36 30 28 30 28 26 32 32 30 30 30 32 32 32 28 36 37 32 40 36 32 37 30
NF001 NF002 NF003 NF004 NF005 NF006 NF007 NF008 NF009 NF010 NF011 NF012 NF013 NF014 NF015 NF016 NF017 NF018 NF019 NF020 NF021 NF022 NF023 NF024 NF025 NF026 NF027 NF028 NF029 NF030 NF031 NF032
55 52 59 54 60 78 72 59 53 61 70 54 70 65 83 78 53 52 71 51 58 58 68 50 51 63 60 79 50 55 85 54
102 80 92 95 88 78 76 92 85 105 90 80 87 88 72 88 90 78 96 106 87 88 72 87 70 95 90 101 84 94 94 100
90 68 79 84 75 66 68 78 72 90 79 69 75 70 63 82 74 70 83 87 78 75 62 75 64 78 81 92 72 78 77 85
134 122 124 120 138 129 124 128 131 138 126 130 128 138 130 115 130 131 132 132 128 135 138 136 150 130 122 135 140 146 135 134
32 22 32 34 30 30 28 34 28 38 29 32 28 31 30 28 31 28 27 27 28 28 26 30 26 28 30 34 28 29 32 37
F001 F002 F003 F004 F005 F006 F007 F008 F009 F010 F011 F012 F013 F014 F015 F016 F017 F018 F019 F020 F021 F022 F023 F024 F025 F026 F027 F028 F029 F030 F031 F032
Notes: HAL, hip axis length (mm); FNAL, femur neck axis length (mm); FNA, femur neck angle (8); NW, neck width (mm).
Table 2 – The average of hip geometry measurement in each group. Contrast Femoral neck fracture patients Controls Age group I (45–54 years old) Age group II (55–64 years old) Age group III (>64 years old)
HAL (x SD)
FNAL (x SD)
FNA (x SD)
NW (x SD)
90.2 8.6 88.4 9.4 90.0 10.9 90.8 6.6 88.2 8.6
77.2 7.3 76.2 7.9 77.6 9.0 77.6 6.3 75.8 7.4
131.7 6.2 131.5 7.3 132.7 7.9 132.1 7.2 130.8 5.9
32.3 3.4 29.8 3.3 30.5 4.4 30.6 2.7 31.6 3.3
Notes: X, average; SD, standard deviation; HAL, hip axis length (mm); FNAL, femur neck axis length (mm); FNA, femur neck angle (8); NW, neck width (mm).
Table 3 – Summary of ORs and 95%CIs regarding the correlation of hip geometry measurements and femoral neck fracture. No.
1 2 3 4 5
Parameters
HAL FNAL FNA NW Age group
Femoral neck fracture risk OR
95%CI
P-value
1.050 0.989 0.915 1.311 1.872
0.847–1.302 0.899–1.089 0.721–1.163 1.055–1.630 0.941–3.723
0.655 0.828 0.468 0.015 0.074
Notes: OR, odds ratio; CI, confidence interval; HAL, hip axis length; FNAL, femur neck axis length; FNA, femur neck angle; NW, neck width.
geometry and it is expected to be a predilection factor for femoral neck fractures. This study reported regarding hip geometry measurement in older women. Data regarding the results of this study are described in Tables 1–3. Hip geometry measurement in this study had a difference with the results of several studies in the world. Nakamura et al.14 reported the differences of hip geometry in the Japanese (FNAL = 4.4 cm, NW = 0.57 cm, FNA = 1288) and the American population (FNAL = 5.6 cm, NW = 0.99 cm, FNA = 1308). Nelson et al.17 reported the differences of hip geometry in the African (FNAL = 4.74 cm, FNA = 130.18, NW = 0.94 cm), Mexican (FNAL = 4.64 cm, FNA = 131.18, NW = 0.91 cm), and the American population (FNAL = 4.62 cm, FNA = 131.18, NW = 0.92 cm), while the results of this study showed that the average
Please cite this article in press as: Fajar JK, et al. Hip geometry to predict femoral neck fracture: Only neck width has significant association, Apollo Med. (2016), http://dx.doi.org/10.1016/j.apme.2016.05.005
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numbers of hip geometry (HAL, FNAL, FNA, and NW) measurement in patients with femoral neck fracture were 90.2 8.6 mm; 77.2 7.3 mm; 131.7 6.28; 32.3 3.4 mm, respectively, and in controls group were 88.4 9.4 mm; 76.2 7.9 mm; 131.5 7.38; 29.8 3.3 mm, respectively. These data indicated that FNAL and NW of Aceh population were longer than Japanese, American, Mexican, and African population, while FNA of Aceh population was not too much different compared with Japanese, American, Mexican, and African population. This difference could be due to race, and ethnicity had important roles in hip geometry measurement results. HAL is the distance from pelvic rim to outer margin of greater trochanter along neck axis.13 This study reported the relationship between HAL measurement and the risk of femoral neck fractures. The results of this study showed that there was no significant association between HAL measurement and the risk of femoral neck fractures (OR95%CI = 1.050 [0.847–1.302] P = 0.655). These results had differences with the results of several studies. Im and Lim16 studied regarding the association of hip geometry with the risk of femoral neck fractures in the Korean population. They showed that HAL of patients with femoral neck fractures was higher than in the control group. Faulkner et al.20 studied regarding the efficacy of hip geometry to the incidence of femoral neck fractures. They showed that the HAL measurement had a significant association with the incidence of femoral neck fractures. Crabtree et al.11 studied regarding the efficacy of HAL measurement to the incidence of femoral neck fractures. They showed that the HAL measurement had a significant association with the incidence of femoral neck fractures. But the results of this study had compatibility with a study conducted by Peacock et al.21 They showed that the HAL measurement had no significant correlation with the incidence of femoral neck fractures, but HAL measurement combined with BMD had a significant correlation with the incidence of femoral neck fractures. FNAL is distance from user-defined center of femoral head to intersection of neck and shaft axes.13 This study reported the relationship between FNAL measurement and the risk of femoral neck fracture. The results of this study showed that there was no significant association between FNAL measurement and the risk of femoral neck fracture (OR95%CI = 0.989 [0.899–1.089] P = 0.828). These results had differences with the results of several studies. Kaptoge et al.22 investigated the incidence of femoral neck fractures using hip geometry. They indicated that the incidence of femoral neck fractures had a significant correlation with FNAL measurements. Crabtree et al.11 studied regarding the efficacy of FNAL measurements to predict the incidence of femoral neck fractures. They indicated that the FNAL measurement had a significant association with the incidence of femoral neck fractures. The study conducted by Dincel et al.23 investigated the association of hip geometry with the incidence of femoral neck fractures. They found that the FNAL measurement was correlated with the incidence of femoral neck fractures. FNA is the angle between derived axes of neck and shaft.13 This study reported the relationship between FNA measurement and the risk of femoral neck fracture. The results of this study showed that there was no significant association between the FNA measurement and the risk of femoral neck
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fracture (OR95%CI = 0.915 [0.721–1.163] P = 0.468). These results had differences with a study by Im and Lim.16 They studied regarding the association of hip geometry with the risk of femoral neck fractures in the Korean population. They showed that FNA of patients with femoral neck fractures was higher than in the control group. However, the results of this study had a similarity with a study conducted by Faulkner et al.,20 which indicated that the FNA measurement did not have a significant association with the risk of femoral neck fractures. NW is the width of the femoral neck.13 This study reported the relationship between NW measurement and the risk of femoral neck fracture. The results of this study indicated that there was a significant association between NW measurement and the risk of femoral neck fracture (OR95%CI = 1.311 [1.055– 1.630] P = 0.015). These results have similarities with results of several studies. Im and Lim16 studied regarding the association of hip geometry with the risk of femoral neck fractures in the Korean population. They found that NW of patients with femoral neck fractures was higher than in the control group. Kaptoge et al.22 studied regarding the incidence of femoral neck fractures using hip geometry. They indicated that the incidence of femoral neck fractures had a significant correlation with NW measurements. The study conducted by Dincel et al.23 showed that the NW measurement had a significant association with the incidence of femoral neck fractures. However, a study conducted by Faulkner et al.20 had differences with these results. They found that NW measurement did not have a significant correlation with the incidence of femoral neck fractures. Processes that underlie the association between hip geometry and femoral neck fractures were allegedly caused by several factors, i.e.: osteoporosis, menopause, and age. Osteoporosis is defined as low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk.24 The incidence of osteoporosis is increased in the elderly. Osteoporosis often occurs in postmenopause women. Osteoporosis has a significant correlation to the incidence of fracture.25 Studies conducted by Landfeldt et al.26 had shown that the treatment of osteoporosis regularly had been associated to decreased risk of fractures. The correlation of osteoporosis and fractures is possible due to changes in the metabolism of the components needed by bone tissue.25 Osteoporosis has been associated with the degenerative process. This involves several factors. The study conducted by Anagnostis et al.27 revealed that several factors involved in the process of osteoporosis are bone mineral, estrogen deficiency, parathyroid hormone, homocysteine, lipid oxidation product, inflammation, and vitamin D and K. However, vitamin D alone does not fully reflect the occurrence of osteoporosis and femoral neck fractures. The study by Vagadia et al.28 showed that low level of vitamin D did not always correlate to decrease of bone density. Osteoporosis also had a correlation with the age of menopause. Sioka et al.29 showed that menopause at age 40 and 45 years had a correlation with lower BMD. However, the occurrence of primary osteoporosis is complex. There are many theories that explain the process. Li et al.30 described the role of microRNA (miRNA) to the occurrence of primary osteoporosis. They explained that miRNA (miR-2861) plays an important role in the osteoblast differentiation by suppressing
Please cite this article in press as: Fajar JK, et al. Hip geometry to predict femoral neck fracture: Only neck width has significant association, Apollo Med. (2016), http://dx.doi.org/10.1016/j.apme.2016.05.005
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the histone deacetylase 5 (HDAC 5) expression. miR-2861 silencing caused a decrease of runt-related transcription factor 2 (RUNX 2) expression, inhibition of bone formation, and bone loss. Furthermore, a study by Tokuzawa et al.31 had shown a correlation of ID4 gene with primary osteoporosis. The gene played an important role in the osteoblasts by mediating the release of Hes 1 from the Hes1–Hey 2 complex. Hes-1 increased stability of RUNX 2 transcriptional activity, thus causing an increase of genes expression in the osteoblasts process. Therefore, a decrease of ID4 had a big role in the occurrence of osteoporosis. Estrogen levels have a significant effect on the occurrence of osteoporosis. The process occurs through the stimulation of the immune system and the disruption of osteoclast and osteoblast regulation.32 So, these mechanisms (old age, menopause, and osteoporosis), as risk factor for femoral neck fractures, were the entity that had an important role to cause the differences of hip geometry measurement in this study. There were several limitations in the study. First, this study did not include data regarding the factors associated with osteoporosis and femoral neck fractures, i.e.: body mass index, years since menopause, physical activity, smoking status, alcohol consumption, use of corticosteroids, and diabetes. Second, false negative results could have occurred in this study due to the small sample size. Therefore, further studies with a larger sample size are needed to determine the actual association. Third, the results of this study did not fully reflect the Aceh population because samples were recruited only from Dr. Zainoel Abidin Teaching Hospital.
5.
Conclusions and suggestions
Our study found that HAL, FNAL, and FNA measurements did not have a significant association with femoral neck fracture, but NW measurement had a significant association with the incidence of femoral neck fractures. Further studies are needed regarding the correlation of hip geometry with the risk of femoral neck fracture in Aceh population using a larger and prevalent sample size and involving several factors that play a role in the process of osteoporosis and femoral neck fractures.
Conflicts of interest The authors have none to declare.
references
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25. Manninger J, Bosch U, Cserhati P, Fekete K, Kazar G. Internal Fixation of Femoral Neck Fractures: An Atlas. Stefan: SpringerVerlag; 2007. 26. Landfeldt E, Ström O, Robbins S, Borgström F. Adherence to treatment of primary osteoporosis and its association to fractures—the Swedish Adherence Register Analysis (SARA). Osteoporos Int. 2012;23(2):433–443. 27. Anagnostis P, Karagiannis A, Kakafika AI, Tziomalos K, Athyros VG, Mikhailidis DP. Atherosclerosis and osteoporosis: age-dependent degenerative processes or related entities? Osteoporos Int. 2009;20(2):197–207. 28. Vagadia V, Bartholomew P, Kelly M, Handley G, Kelly C. Osteoporosis and metabolic bone disease: do low vitamin D levels predict osteoporosis? Rheumatology. 2011;50(3): iii69–iii74. 29. Sioka C, Fotopoulos A, Georgiou A, Xourgia X, Papadopoulos A, Kalef-Ezra JA. Age at menarche: age at menopause and
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duration of fertility as risk factors for osteoporosis. Climacteric. 2010;13(1):63–71. Li H, Xie H, Liu W, et al. A novel microRNA targeting HDAC5 regulates osteoblast differentiation in mice and contributes to primary osteoporosis in humans. J Clin Investig. 2009;119 (12):3666–3677. Tokuzawa Y, Yagi K, Yamashita Y, et al. Id4, a new candidate gene for senile osteoporosis, acts as a molecular switch promoting osteoblast differentiation. PLoS Genet. 2010;6(7):e1001019. Novack DV. Estrogen and bone: osteoclasts take center stage. Cell Metab. 2009;6:254–256. Gregory JS, Aspden RM. Femoral geometry as a risk factor for osteoporotic hip fracture in men and women. Med Eng Phys. 2008;30(10):1275–1286.
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/apme
Research Article
Hip geometry to predict femoral neck fracture: Only neck width has significant association§ Jonny Karunia Fajar a,*, Rusydi Rusydi b, Safrizal Rahman c, Armia Indra Nur Alam c, Azharuddin Azharuddin c a
Medical Research Unit, School of Medicine, University of Syiah Kuala, Banda Aceh 23111, Indonesia Resident of General Surgery, School of Medicine, University of Syiah Kuala, Banda Aceh, Indonesia c Department of Orthopedic and Traumatology, School of Medicine, University of Syiah Kuala, Dr. Zainoel Abidin Teaching Hospital, Banda Aceh, Indonesia b
article info
abstract
Article history:
Background: Efficacy of the use of hip geometry to predict femoral neck fracture is contro-
Received 14 May 2016
versial and it is influenced by the particular race. Studies on the use of hip geometry in
Accepted 27 May 2016
Aceh's population have never been done.
Available online xxx
Objectives: To determine the association of hip geometry with femoral neck fracture in
Keywords:
Methods: This study was an observational analysis. The design of this study was cross-
Femoral neck fracture
sectional. The study was conducted in Dr. Zainoel Abidin Teaching Hospital from May to
Hip geometry
August 2013. Hip geometry measurements were done, such as the following: hip axis length
elderly women in Dr. Zainoel Abidin Teaching Hospital.
Hip axis length
(HAL), femoral neck axis length (FNAL), femoral neck angle (FNA), and neck width (NW).
Femoral neck angle
Statistical analysis used was logistic regression test.
Neck width
Results: A total of 32 patients with femoral neck fractures and 32 control patients were followed in this study. The average value of hip geometry measurements in femoral neck fracture was HAL = 90.2 8.6, FNAL = 77.2 7.3, FNA = 131.7 6.2, NW = 32.3 3.4; and in nonfemoral neck fracture, it was HAL = 88.4 9.4, FNAL = 76.2 7.9, FNA = 131.5 7.3, NW = 29.8 3.3. Measurement HAL, FNAL, and FNA did not have a significant association with the incidence of femoral neck fracture (P > 0.05). However, NW measurement had a significant association with the incidence of femoral neck fracture (P < 0.05). Conclusion: Only NW measurement had a significant association with femoral neck fracture in older women in Dr. Zainoel Abidin Teaching Hospital. # 2016 Indraprastha Medical Corporation Ltd. All rights reserved.
§ This paper was presented in the 6th Annual Basic Science International Conference – University of Brawijaya 2016, Malang, Indonesia, on March 3rd, 2016. * Corresponding author. Tel.: +62 081235522287; fax: +62 0651 7551843. E-mail address: [email protected] (J.K. Fajar). http://dx.doi.org/10.1016/j.apme.2016.05.005 0976-0016/# 2016 Indraprastha Medical Corporation Ltd. All rights reserved.
Please cite this article in press as: Fajar JK, et al. Hip geometry to predict femoral neck fracture: Only neck width has significant association, Apollo Med. (2016), http://dx.doi.org/10.1016/j.apme.2016.05.005
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1.
Introduction
Fracture is a serious health problem. Annual direct care expenditures for fractures is about 1 trillion dollars in the United Kingdom (UK) and indirect costs (e.g., lost productivity for patients and caregivers) likely add billions of dollars to this figure.1 Fracture is a major cause of mortality and morbidity in the elderly.2 Fracture in the elderly is associated with decreased quality of life so that even minimal trauma can cause serious repercussions. There are three regions that are often affected by fractures in osteoporotic patients, i.e.: femoral neck, spine, and distal radius.3 The incidence of femoral neck fractures was 957.3 cases per 100,000 female and 414.4 cases per 100,000 United States (US) male population in 1986–2005,4 400 cases per 100,000 US population per year in 2010,5 and less than 200 per 100,000 Indonesian women per year in 2012.6 The incidence of femoral neck fractures was more common in postmenopause than premenopause women7 or in age ≥64 years.4 A study regarding femoral neck fractures has not been done in Aceh. Demographic data regarding the incidence of fractures around the World estimated that there would be an increase of femoral neck fractures incidence from about 1.7 million in 1990 to 6 million cases in 2050.8 Although the incidence of femoral neck fractures is often caused by trauma, these fractures also have a close association with osteoporosis.9 Osteoporosis is defined as low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk or bone mineral density (BMD) that is 2.5 standard deviations (SDs) or more below the young adult mean value.10 Hip geometry and BMD have been associated as a predilection of femoral neck fractures incidence.11 BMD is a marker of bone strength measurement. However, BMD does not fully reflect femoral neck fractures. Lewicki and Borges12 conducted a clinical study regarding femoral neck fractures using BMD. The results showed that the incidence of osteoporosis was only 40–50% of all patients with femoral neck fractures. This indicated that BMD reflected only partially. This is possible because bone strength is determined by several factors, including BMD, bone architecture (hip geometry), microarchitecture, matrix components, tissue mineral density, and bone damage.13 Hip geometry is the examination of bone strength based on the measurement of proximal femur geometry. Hip geometry measurement includes hip axis length (HAL) – the distance from pelvic rim to outer margin of greater trochanter along neck axis, femoral neck axis length (FNAL) – distance from user-defined center of femoral head to intersection of neck and shaft axes, femoral neck angle (FNA) – angle between derived axes of neck and shaft, and neck width (NW) – the width of the femoral neck.13 The results of hip geometry measurement are thought to be different for each tribe. Several studies have reported differences of hip geometry. Nakamura et al.14 reported hip geometry differences of Japanese (FNAL: 4.4 cm, NW: 0.57 cm, FNA: 1280) and American population (FNAL: 5.6 cm, NW: 0.99 cm, FNA; 1300), Theobald et al.15 reported hip geometry differences of the white and the black of America population where the black population has NW and
FNAL 25% lower than whites; Im and Lim16 reported hip geometry differences of Korean population; Nelson et al.17 reported hip geometry differences of African (FNAL: 4.74 cm, FNA: 130.10, NW: 0.94 cm), Mexican (FNAL: 4.64 cm, FNA: 131.10, NW; 0, 91 cm), and American population (FNAL: 4.62 cm, FNA: 131.10, NW; 0.92 cm), and LaCroix et al.18 reported hip geometry differences of American population. The use of hip geometry possible will give better results regarding femoral neck fractures. In addition, the study regarding hip geometry in Aceh population has never been done. Therefore, it is necessary to study regarding the association of hip geometry with the risk of femoral neck fractures in older women in Dr. Zainoel Abidin Teaching Hospital.
2.
Methods
2.1.
Study designs and participants
This study was a cross-sectional study conducted in Clinic of Orthopaedic and Radiology Installation in Dr. Zainoel Abidin Teaching Hospital from May 2013 to August 2013. The target population was all elderly women with femoral neck fractures (358 patients – updated 5 March 2013) treated in Dr. Zainoel Abidin Teaching Hospital. Inclusion criteria for this study were as follows: (1) suffered femoral neck fractures, (2) women aged over 45 years, (3) got inadequate trauma, (4) had Singh index less than 3, and (5) postmenopause women. The exclusion criteria in this study were as follows: (1) not willing to be the subject of study, both orally and written, (2) had multitrauma with high energy, (3) long bed rest, and (4) young people with osteoporosis caused by various diseases. A simple, random sampling method was used to select 358 population-representative patients. The sample of this study was 32 patients and 32 controls as the minimum sample size. Ethical approval was obtained from The Ethical Clearance Committee of School of Medicine, Syiah Kuala University, Banda Aceh, Indonesia. All patients were given explanation about the purpose, risks, and benefits, and written informed consent of study prior to the examination was obtained. Patients were informed that they could terminate the study at any time. Patients in this study were voluntary and patients received no incentive.
2.2.
Hip imaging and hip structural analysis
Hip imaging, including X-ray and CT scan, was conducted in Radiology Installation in Dr. Zainoel Abidin Teaching Hospital. Radiology imaging was interpreted by radiologists to determine femoral neck fracture and Singh index. Hip structural analysis (HSA) was conducted in Clinic of Orthopaedic in Dr. Zainoel Abidin Teaching Hospital. X-ray imaging was analyzed for HSA manually using a ruler. HSA in this study included HAL, FNAL, FNA, and NW measurements. The sketch of hip geometry measurement was described in Fig. 1.
2.3.
Study variables
1. Femoral neck fracture Femoral neck fracture is the fracture in femoral neck.9 Ordinal scale was used to assess this variable. These
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Fig. 1 – The scheme of hip geometry measurement.33 HAL, distance from pelvic rim to outer margin of greater trochanter along neck axis (A–C). FNAL, distance from user-defined center of femoral head to intersection of neck and shaft axes (B–C). FNA, angle between derived axes of neck and shaft (H). NW, the width of the femoral neck (F–G).13
2.
3.
4.
5.
variable measurement results were fracture and nonfracture. Hip X-ray and CT scan were used to assess this variable. Hip axis length (HAL) HAL is the distance from pelvic rim to outer margin of greater trochanter along neck axis.13 Ratio scale was used to assess this variable. These variable measurement results were numbers. Femoral neck axis length (FNAL) FNAL is distance from user-defined center of femoral head to intersection of neck and shaft axes.13 Ratio scale was used to assess this variable. These variable measurement results were numbers. Femoral neck angle (FNA) FNA is the angle between derived axes of neck and shaft.13 Ratio scale was used to assess this variable. These variable measurement results were numbers. Neck width (NW) NW is the width of the femoral neck.13 Ratio scale was used to assess this variable. These variable measurement results were numbers.
2.4.
Statistical analysis
Data were analyzed using univariate and bivariate analysis. Data regarding the relationship of femoral neck fractures with hip geometry were analyzed using bivariate analysis. Bivariate analysis used to assess these variables was logistic regression test using SPSS software. P < 0.05 was considered significant statistically.19
3.
Results
A total of 32 of 385 femoral neck fracture patients were selected for the study using random numbers. Of these, 13 patients had died. Therefore, the selection was continued to get 13 patients more. After getting 32 femoral neck fracture patients, five patients were excluded because they had Singh index four (one patient), had long bed rest (two patients), and got trauma with
high energy (two patients). The selection was continued to get five patients more. Controls were obtained from nonfracture patients in Dr. Zainoel Abidin Teaching Hospital. A total of 32 femoral neck fracture patients and 32 controls were recruited for the study. Participants of the study were 50– 89 years old; of these, 26.6% (17 participants) were 45–54 years old, 23.4% (15 participants) were 55–64 years old, and 50% (32 participants) were more than 64 years old. Table 1 summarizes study characteristics of 64 participants in the study. The average numbers of hip geometry (HAL, FNAL, FNA, and NW) measurement in patients with femoral neck fracture were 90.2 8.6 mm; 77.2 7.3 mm; 131.7 6.28; 32.3 3.4 mm, respectively, while the average numbers of hip geometry measurement in controls group were 88.4 9.4 mm; 76.2 7.9 mm; 131.5 7.38; 29.8 3.3 mm, respectively. In age group, the average numbers of hip geometry measurement of age group I (45–54 years old) were 90.0 10.9 mm; 77.6 9.0 mm; 132.7 7.98; 30.5 4.4 mm; for age group II (55–64 years old) were 90.8 6.6 mm; 77.6 6.3 mm; 132.1 7.28; 30.6 2.7 mm, and for age group III (>64 years old) were 88.2 8.6 mm; 75.8 7.4 mm; 130.8 5.98; 31.6 3.3 mm, respectively. Table 2 summarized the average numbers of hip geometry measurements in various groups. The study found that not all hip geometry parameters correlated with femoral neck fracture. This study found that there was a significant positive correlation between NW and the risk of femoral neck fracture (OR95%CI = 1.311 [1.055–1.630] P = 0.015) (Table 3), while no association was found between risk of femoral neck fracture and other parameters, i.e.: HAL (OR95%CI = 1.050 [0.847–1.302] P = 0.655), FNAL (OR95% CI = 0.989 [0.899–1.089] P = 0.828), FNA (OR95%CI = 0.915 [0.721–1.163] P = 0.468), and age group (OR95%CI = 1.872 [0.941–3.723] P = 0.074). Table 3 summarized the correlation of the risk of femoral neck fracture and other parameters.
4.
Discussion
Femoral neck fractures are a serious health problem and often occur in older women. Hip geometry is an examination of bone strength based on the measurement of the proximal femur
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Table 1 – Hip geometry measurements in the study. Femoral neck fracture patients Study ID no.
Controls
Age
HAL
FNAL
FNA
NW
Study ID no.
Age
HAL
FNAL
FNA
NW
54 77 89 54 75 52 66 65 72 73 71 83 66 54 80 71 75 74 64 60 72 84 61 60 68 66 70 74 52 85 54 62
96 83 88 90 101 82 90 87 90 86 88 82 96 95 80 88 92 74 90 86 85 90 90 78 87 110 90 100 112 94 100 85
83 73 73 80 85 68 76 78 77 77 74 69 84 88 65 74 80 66 76 75 76 80 76 65 72 90 80 84 96 77 85 70
129 122 129 130 126 135 135 120 138 134 128 134 130 124 130 130 128 124 135 120 132 132 135 128 140 138 132 140 148 135 134 140
34 35 35 35 33 26 30 35 34 36 30 28 30 28 26 32 32 30 30 30 32 32 32 28 36 37 32 40 36 32 37 30
NF001 NF002 NF003 NF004 NF005 NF006 NF007 NF008 NF009 NF010 NF011 NF012 NF013 NF014 NF015 NF016 NF017 NF018 NF019 NF020 NF021 NF022 NF023 NF024 NF025 NF026 NF027 NF028 NF029 NF030 NF031 NF032
55 52 59 54 60 78 72 59 53 61 70 54 70 65 83 78 53 52 71 51 58 58 68 50 51 63 60 79 50 55 85 54
102 80 92 95 88 78 76 92 85 105 90 80 87 88 72 88 90 78 96 106 87 88 72 87 70 95 90 101 84 94 94 100
90 68 79 84 75 66 68 78 72 90 79 69 75 70 63 82 74 70 83 87 78 75 62 75 64 78 81 92 72 78 77 85
134 122 124 120 138 129 124 128 131 138 126 130 128 138 130 115 130 131 132 132 128 135 138 136 150 130 122 135 140 146 135 134
32 22 32 34 30 30 28 34 28 38 29 32 28 31 30 28 31 28 27 27 28 28 26 30 26 28 30 34 28 29 32 37
F001 F002 F003 F004 F005 F006 F007 F008 F009 F010 F011 F012 F013 F014 F015 F016 F017 F018 F019 F020 F021 F022 F023 F024 F025 F026 F027 F028 F029 F030 F031 F032
Notes: HAL, hip axis length (mm); FNAL, femur neck axis length (mm); FNA, femur neck angle (8); NW, neck width (mm).
Table 2 – The average of hip geometry measurement in each group. Contrast Femoral neck fracture patients Controls Age group I (45–54 years old) Age group II (55–64 years old) Age group III (>64 years old)
HAL (x SD)
FNAL (x SD)
FNA (x SD)
NW (x SD)
90.2 8.6 88.4 9.4 90.0 10.9 90.8 6.6 88.2 8.6
77.2 7.3 76.2 7.9 77.6 9.0 77.6 6.3 75.8 7.4
131.7 6.2 131.5 7.3 132.7 7.9 132.1 7.2 130.8 5.9
32.3 3.4 29.8 3.3 30.5 4.4 30.6 2.7 31.6 3.3
Notes: X, average; SD, standard deviation; HAL, hip axis length (mm); FNAL, femur neck axis length (mm); FNA, femur neck angle (8); NW, neck width (mm).
Table 3 – Summary of ORs and 95%CIs regarding the correlation of hip geometry measurements and femoral neck fracture. No.
1 2 3 4 5
Parameters
HAL FNAL FNA NW Age group
Femoral neck fracture risk OR
95%CI
P-value
1.050 0.989 0.915 1.311 1.872
0.847–1.302 0.899–1.089 0.721–1.163 1.055–1.630 0.941–3.723
0.655 0.828 0.468 0.015 0.074
Notes: OR, odds ratio; CI, confidence interval; HAL, hip axis length; FNAL, femur neck axis length; FNA, femur neck angle; NW, neck width.
geometry and it is expected to be a predilection factor for femoral neck fractures. This study reported regarding hip geometry measurement in older women. Data regarding the results of this study are described in Tables 1–3. Hip geometry measurement in this study had a difference with the results of several studies in the world. Nakamura et al.14 reported the differences of hip geometry in the Japanese (FNAL = 4.4 cm, NW = 0.57 cm, FNA = 1288) and the American population (FNAL = 5.6 cm, NW = 0.99 cm, FNA = 1308). Nelson et al.17 reported the differences of hip geometry in the African (FNAL = 4.74 cm, FNA = 130.18, NW = 0.94 cm), Mexican (FNAL = 4.64 cm, FNA = 131.18, NW = 0.91 cm), and the American population (FNAL = 4.62 cm, FNA = 131.18, NW = 0.92 cm), while the results of this study showed that the average
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numbers of hip geometry (HAL, FNAL, FNA, and NW) measurement in patients with femoral neck fracture were 90.2 8.6 mm; 77.2 7.3 mm; 131.7 6.28; 32.3 3.4 mm, respectively, and in controls group were 88.4 9.4 mm; 76.2 7.9 mm; 131.5 7.38; 29.8 3.3 mm, respectively. These data indicated that FNAL and NW of Aceh population were longer than Japanese, American, Mexican, and African population, while FNA of Aceh population was not too much different compared with Japanese, American, Mexican, and African population. This difference could be due to race, and ethnicity had important roles in hip geometry measurement results. HAL is the distance from pelvic rim to outer margin of greater trochanter along neck axis.13 This study reported the relationship between HAL measurement and the risk of femoral neck fractures. The results of this study showed that there was no significant association between HAL measurement and the risk of femoral neck fractures (OR95%CI = 1.050 [0.847–1.302] P = 0.655). These results had differences with the results of several studies. Im and Lim16 studied regarding the association of hip geometry with the risk of femoral neck fractures in the Korean population. They showed that HAL of patients with femoral neck fractures was higher than in the control group. Faulkner et al.20 studied regarding the efficacy of hip geometry to the incidence of femoral neck fractures. They showed that the HAL measurement had a significant association with the incidence of femoral neck fractures. Crabtree et al.11 studied regarding the efficacy of HAL measurement to the incidence of femoral neck fractures. They showed that the HAL measurement had a significant association with the incidence of femoral neck fractures. But the results of this study had compatibility with a study conducted by Peacock et al.21 They showed that the HAL measurement had no significant correlation with the incidence of femoral neck fractures, but HAL measurement combined with BMD had a significant correlation with the incidence of femoral neck fractures. FNAL is distance from user-defined center of femoral head to intersection of neck and shaft axes.13 This study reported the relationship between FNAL measurement and the risk of femoral neck fracture. The results of this study showed that there was no significant association between FNAL measurement and the risk of femoral neck fracture (OR95%CI = 0.989 [0.899–1.089] P = 0.828). These results had differences with the results of several studies. Kaptoge et al.22 investigated the incidence of femoral neck fractures using hip geometry. They indicated that the incidence of femoral neck fractures had a significant correlation with FNAL measurements. Crabtree et al.11 studied regarding the efficacy of FNAL measurements to predict the incidence of femoral neck fractures. They indicated that the FNAL measurement had a significant association with the incidence of femoral neck fractures. The study conducted by Dincel et al.23 investigated the association of hip geometry with the incidence of femoral neck fractures. They found that the FNAL measurement was correlated with the incidence of femoral neck fractures. FNA is the angle between derived axes of neck and shaft.13 This study reported the relationship between FNA measurement and the risk of femoral neck fracture. The results of this study showed that there was no significant association between the FNA measurement and the risk of femoral neck
5
fracture (OR95%CI = 0.915 [0.721–1.163] P = 0.468). These results had differences with a study by Im and Lim.16 They studied regarding the association of hip geometry with the risk of femoral neck fractures in the Korean population. They showed that FNA of patients with femoral neck fractures was higher than in the control group. However, the results of this study had a similarity with a study conducted by Faulkner et al.,20 which indicated that the FNA measurement did not have a significant association with the risk of femoral neck fractures. NW is the width of the femoral neck.13 This study reported the relationship between NW measurement and the risk of femoral neck fracture. The results of this study indicated that there was a significant association between NW measurement and the risk of femoral neck fracture (OR95%CI = 1.311 [1.055– 1.630] P = 0.015). These results have similarities with results of several studies. Im and Lim16 studied regarding the association of hip geometry with the risk of femoral neck fractures in the Korean population. They found that NW of patients with femoral neck fractures was higher than in the control group. Kaptoge et al.22 studied regarding the incidence of femoral neck fractures using hip geometry. They indicated that the incidence of femoral neck fractures had a significant correlation with NW measurements. The study conducted by Dincel et al.23 showed that the NW measurement had a significant association with the incidence of femoral neck fractures. However, a study conducted by Faulkner et al.20 had differences with these results. They found that NW measurement did not have a significant correlation with the incidence of femoral neck fractures. Processes that underlie the association between hip geometry and femoral neck fractures were allegedly caused by several factors, i.e.: osteoporosis, menopause, and age. Osteoporosis is defined as low bone mass and microarchitectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk.24 The incidence of osteoporosis is increased in the elderly. Osteoporosis often occurs in postmenopause women. Osteoporosis has a significant correlation to the incidence of fracture.25 Studies conducted by Landfeldt et al.26 had shown that the treatment of osteoporosis regularly had been associated to decreased risk of fractures. The correlation of osteoporosis and fractures is possible due to changes in the metabolism of the components needed by bone tissue.25 Osteoporosis has been associated with the degenerative process. This involves several factors. The study conducted by Anagnostis et al.27 revealed that several factors involved in the process of osteoporosis are bone mineral, estrogen deficiency, parathyroid hormone, homocysteine, lipid oxidation product, inflammation, and vitamin D and K. However, vitamin D alone does not fully reflect the occurrence of osteoporosis and femoral neck fractures. The study by Vagadia et al.28 showed that low level of vitamin D did not always correlate to decrease of bone density. Osteoporosis also had a correlation with the age of menopause. Sioka et al.29 showed that menopause at age 40 and 45 years had a correlation with lower BMD. However, the occurrence of primary osteoporosis is complex. There are many theories that explain the process. Li et al.30 described the role of microRNA (miRNA) to the occurrence of primary osteoporosis. They explained that miRNA (miR-2861) plays an important role in the osteoblast differentiation by suppressing
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the histone deacetylase 5 (HDAC 5) expression. miR-2861 silencing caused a decrease of runt-related transcription factor 2 (RUNX 2) expression, inhibition of bone formation, and bone loss. Furthermore, a study by Tokuzawa et al.31 had shown a correlation of ID4 gene with primary osteoporosis. The gene played an important role in the osteoblasts by mediating the release of Hes 1 from the Hes1–Hey 2 complex. Hes-1 increased stability of RUNX 2 transcriptional activity, thus causing an increase of genes expression in the osteoblasts process. Therefore, a decrease of ID4 had a big role in the occurrence of osteoporosis. Estrogen levels have a significant effect on the occurrence of osteoporosis. The process occurs through the stimulation of the immune system and the disruption of osteoclast and osteoblast regulation.32 So, these mechanisms (old age, menopause, and osteoporosis), as risk factor for femoral neck fractures, were the entity that had an important role to cause the differences of hip geometry measurement in this study. There were several limitations in the study. First, this study did not include data regarding the factors associated with osteoporosis and femoral neck fractures, i.e.: body mass index, years since menopause, physical activity, smoking status, alcohol consumption, use of corticosteroids, and diabetes. Second, false negative results could have occurred in this study due to the small sample size. Therefore, further studies with a larger sample size are needed to determine the actual association. Third, the results of this study did not fully reflect the Aceh population because samples were recruited only from Dr. Zainoel Abidin Teaching Hospital.
5.
Conclusions and suggestions
Our study found that HAL, FNAL, and FNA measurements did not have a significant association with femoral neck fracture, but NW measurement had a significant association with the incidence of femoral neck fractures. Further studies are needed regarding the correlation of hip geometry with the risk of femoral neck fracture in Aceh population using a larger and prevalent sample size and involving several factors that play a role in the process of osteoporosis and femoral neck fractures.
Conflicts of interest The authors have none to declare.
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Please cite this article in press as: Fajar JK, et al. Hip geometry to predict femoral neck fracture: Only neck width has significant association, Apollo Med. (2016), http://dx.doi.org/10.1016/j.apme.2016.05.005
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