The Effects of Age, Adiposity, and Physical Activity on the Risk of Seven Site-Specific Fractures in Postmenopausal Women

Bone health in adults with obesity before and after interventions to promote weight loss

Obesity and its associated comorbidities constitute a serious and growing public health burden. Fractures affect a substantial proportion of people with obesity and result from reduced bone strength relative to increased mechanical loading, together with an increased risk of falls. Factors contributing to fractures in people with obesity include adverse effects of adipose tissue on bone and muscle and, in many people, the coexistence of type 2 diabetes. Strategies to reduce weight include calorie-restricted diets, exercise, bariatric surgery, and pharmacological interventions with GLP-1 receptor agonists. However, although weight loss in people with obesity has many health benefits, it can also have adverse skeletal effects, with increased bone loss and fracture risk. Priorities for future research include the development of effective approaches to reduce fracture risk in people with obesity and the investigation of the effects of GLP-1 receptor agonists on bone loss resulting from weight reduction.

Causal relationships between height and weight with distal tibia microarchitecture and geometry in adult female twin pairs

Higher stature and lower weight are associated with increased risk of fracture. However, the pathophysiology for the associations of height and weight with bone microarchitecture and geometry is unclear. We examined whether these associations were consistent with causation and/or with shared familial factors. In this cross-sectional study of 566 female twins aged 26-76 yr, a regression analysis for twin data, Inference about Causation by Examination of FAmilial CONfounding (ICE FALCON), was used for testing causation. The bone microarchitecture and geometry of the distal tibia was assessed using HR-pQCT and the StrAx1.0 software. Higher stature was associated with larger total bone cross-sectional area (CSA), lower total bone volumetric bone mineral density (vBMD), larger cortical CSA, thinner cortices, higher porosity of the total cortex, compact cortex, outer and inner transitional zone (TZ), lower cortical vBMD, and larger medullary CSA (regression coefficients (β) ranging from -.37 to .60, all p<.05). Using ICE FALCON, the cross-pair cross-trait associations attenuated toward zero after adjusting for the within-individual association (absolute values of β ranging from .05 to .31, all p<.001). Higher weight was associated with higher total bone vBMD, larger cortical CSA and thicker cortices, lower porosity of the total cortex and inner TZ, and higher cortical vBMD (β ranging from -.23 to .34, all p<.001), and thinner trabeculae, higher trabecular number, lower trabecular separation, and higher trabecular vBMD (β ranging from -.31 to .39, all p<.05). Only cortical CSA attenuated toward zero after adjusting for the within-individual association between weight and bone microarchitecture (β = .042, p=.046). Higher stature was associated with a weaker cortical, not trabecular bone traits, whereas higher weight was associated with stronger cortical and trabecular bone traits. The results were consistent with height having a causal effect on weaker cortical bone structure, whereas weight had a casual effect on the larger cortical CSA.

Primary Hyperparathyroidism and Pulmonary Embolism in Patients With a Fractured Neck of Femur

Two patients aged 82 and 77, with a fractured neck of the femur, were found to have primary hyperparathyroidism, characterized by hypercalcemia and hypercalciuria. Post-surgery, both developed pulmonary embolism (PE), highlighting a possible link between hypercalcemia and increased hypercoagulation risk. There have been few case reports suggesting the association between hypercalcemia due to hyperparathyroidism and the increase in tendency of hypercoagulation and subsequent risk of venous thromboembolism (VTE). This case series offers insights into how ionized calcium influences thrombin formation, platelet activation and aggregation, and activation of clotting factors such as factor VII and factor X, raising questions about the role of chronic hypercalcemia in VTE. Further research is needed to 1) establish whether chronic hypercalcemia in the absence of fracture can modulate the risk of hypercoagulation; 2) determine whether chronic hypercalcemia in individuals with bone fracture may represent a significantly higher hypercoagulability risk during the postoperative periods.

Positive association between blood glucose in physical examinations and self-reported fractures among middle-aged and elderly Japanese men: a prospective cohort study

The association between blood glucose and fractures is not consistent across populations. Blood glucose was associated with fractures five years later in middle-aged and elderly men who underwent health examinations in Japan, respectively. Blood glucose-targeted fracture alerts are crucial for middle-aged and elderly individuals.

OBJECTIVES

The evidence on blood glucose as a fracture risk marker has not been adequately examined in various populations, and there are no studies in middle-aged Japanese. We aimed to determine the association between blood glucose status and self-report fractures among middle-aged and elderly Japanese men.

METHODS

The data from the Japan Multi-Institutional Collaborative Cohort (J-MICC) Okazaki Study were used. Hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) measured at baseline physical examinations were examined for association with fractures questioned five years later. Analyses were performed for the middle-aged and elderly respondents.

RESULTS

The HbA1c was dichotomized into 290 (11.8%) with HbA1c ≥ 6.5% and 2165 (88.2%) with HbA1c < 6.5%. Compared to the group with an HbA1c < 6.5, the odds ratio for the risks of fracture among the group with an HbA1c ≥ 6.5% were 3.46 (95% confidence interval (CI), 1.75-6.84) in Model 1 (adjusted for age) and 3.60 (95% CI, 1.77-7.34) in Model 2 (adjusted for various confounding factors). These associations were also observed in both middle-aged and elderly generations, whereas no association was observed for FPG.

CONCLUSIONS

Among Japanese men who have undergone physical examinations, those with an HbA1c of 6.5% or higher are at higher risk for fractures, and HbA1c-targeted fracture alerts are crucial for middle-aged and elderly individuals.

Hindfoot nailing for displaced ankle fractures in the elderly: A case-control analysis

INTRODUCTION

Management of fragility ankle fractures in the elderly poses a surgical dilemma. An alternative to open reduction and internal fixation (ORIF) with screw and plate construct in selected elderly patients who may be significantly frail and comorbid is a tibio-talo-calcaneal (TTC) or hindfoot nail. Hindfoot nailing potentially reduces the risk of wound infection and increases likelihood of earlier return to function by allowing earlier weightbearing. The aim of this study was to examine the outcomes and complications of patients who received a hindfoot nail compared to patients who underwent an ORIF.

METHODS

A retrospective review identified patients who underwent hindfoot nailing from Jan 2010 to Dec 2021. Patients aged >65-years who underwent ORIF in the same time period were concurrently identified. The patients in the ORIF group were matched with patients in the hindfoot nail group by age, gender, comorbidity according to their Charlson Comorbidity Index (CCI) and their pre-injury function by Karnofsky Performance Scale (KPS). Clinical Frailty Scale (CFS) was also collected as part of patient demographics. Outcomes examined include mortality, length of stay, operation time, return to previous mobility, wound complications, metalware failure and infections.

RESULTS

Twenty-six patients were identified in the hindfoot nail group and matched to 26 patients who underwent ORIF. Mean age was 84 and 83 years in the nail and ORIF group respectively. Overall, there were 12 and 11 complications from the hindfoot nail and ORIF group respectively with seven and two requiring return to theatre in the nail group and ORIF group (P = 0.07). The hindfoot nail group waited an average of 22 days after the operation for weightbearing compared to 59 days in the ORIF group (P < 0.001). There were no significant differences in length of stay (P = 0.58) and operation time (P = 0.19).

CONCLUSION

Hindfoot nailing was associated with an increased risk of complications and higher risk of return to the operating theatre. Despite the potential attraction of earlier weightbearing, surgeons and patients need to be aware of these potential pitfalls.

Bone, cognitive, and anthropometric profiles and their relation to fracture sites in fallers: a cross-sectional study

Risk factors involved in the different osteoporotic fracture locations are not well-known. The results of this study suggest that there is not one typical profile characterising a particular fracture site but that the occurrence of a fracture may result from the combination of different bone, cognitive, and anthropometrics characteristics.

PURPOSE

Risk factors involved in the different osteoporotic fracture locations are not well-known. The aim of this study was to identify the differences in bone, cognitive, and anthropometric characteristics between different fracture sites, and to determine whether the site of a fall-related fracture is related to a specific profile.

METHODS

One hundred six women aged 55 years and older with a recent fall-related fracture of the hip (n = 30), humerus (n = 28), wrist (n = 32), or ankle (n = 16) were included. Bone, cognitive, and anthropometric characteristics were first compared among the four fracture site groups. Then, a principal component analysis (PCA) was performed and a comparison was made between the four profiles identified by the first two PCA components.

RESULTS

The four fracture site groups differed significantly in their education level, bone mineral density (BMD), body mass index (BMI), fear of falling, and number of errors in the Trail Making Test B, an executive function test. Each of the four fracture sites was found in each four PCA profiles, albeit with a different distribution. The profiles differed mainly by bone, cognitive, and anthropometric characteristics, but also by fear of falling.

CONCLUSIONS

The fall-related fracture sites differ significantly in anthropometric and bone parameters, in fear of falling and in cognitive abilities. There is not one typical bone, cognitive, and anthropometric profile characterising a particular fall-related site, but rather several possible profiles for a given site. This suggests that the fracture site depends on a combination of several characteristics of the patient.

Association between total cholesterol and total bone mineral density in US adults: National Health and Nutrition Examination Survey (NHANES), 2011-2018

BACKGROUND

Accumulated evidence indicates that cholesterol is offensive to bone metabolism. Therefore, we examined the real-world study among total cholesterol and total bone mineral density (BMD). We investigated the relationship between total cholesterol and total BMD among 10,039 US participants aged 20-59 years old over the period 2011-2018 from the NHANES.

METHODS

To analyze the relationship among total cholesterol and total BMD, multivariate linear regression models were used. Fitted smoothing curves, generalized additive models, and threshold effect analysis were also conducted.

RESULTS

After adjusting for additional covariates, weighted multivariable linear regression models indicated total cholesterol concentration levels exhibited a negative relationship with total BMD, particularly among participants aged 20-29 years. Concerning subgroup analysis, stratified by gender, race/ethnicity and age group, the negative correlation of total cholesterol with total BMD dwelled in both female and male as well as in whites and other races (including Hispanic and Multi-Racial), but not in non-Hispanic blacks and Mexican American. In other races, this relationship presented a nonlinear association (inflection point: 6.7 mmol/L) with a U-shaped curve. Among participants aged 40 to 49 years, this relationship also followed a nonlinear association (inflection point: 5.84 mmol/L), indicating a saturation effect. Moreover, the three types of diabetes status were found to have negative, U-shaped, and positive relationships. In participants with borderline diabetes status, the relationship of total cholesterol with total BMD was a U-shaped curve (inflection point: 4.65 mmol/L).

CONCLUSIONS

For US young adults (20-29 years old), our study revealed a negative relationship between total cholesterol and total BMD. This association followed a U-shaped curve (inflection point: 4.65 mmol/L) in borderline diabetes status participants, a saturation curve (inflection point: 5.84 mmol/L) in participants aged 40-49 years and a nonlinear curve (inflection point: 6.7 mmol/L) in other races (including Hispanic and Multi-Racial). Therefore, keeping total cholesterol concentration at a reasonable level for young adults and diabetic population might be an approach to prevent osteoporosis or osteopenia.

Trends of incidence and treatment strategies for operatively treated distal fibula fractures from 2005 to 2019: a nationwide register analysis

INTRODUCTION

Valid epidemiological data about distal fibular fractures and their treatment strategies are missing. Innovative osteosynthesis techniques were introduced and improved during the past 15 years. The aim of this study was to investigate the epidemiologic development and the implementation of new treatment strategies in a nationwide register in Germany over a period of 15 years.

MATERIALS AND METHODS

Data of the German Federal Statistical Office from 2005 until 2019 were screened. Adults with a fracture of the distal fibula were included. Data were separated for gender, age and treatment strategy.

RESULTS

During the past 15 years, there was a steady annual incidence of distal fibula fractures of 74 ± 32 per 100,000 people without any significant changes (p = 0.436). 60.1% ± 0.6% of all fractures occurred in females. The annual incidence for male was nearly constant over the different age groups, whereas for female, there was a clear increase in incidence above the age of 40. Whereas 66% of fractures in between 20 and 30 years of age occurred in male, approximately 70% of fractures above the age of 60 occurred in females. The relative quantity of locking plates increased from 2% in 2005 to 34% in 2019. In 2019, only 1.02% of the patients were operated with an intramedullary nail.

CONCLUSIONS

Operatively treated distal fibular fractures revealed an age dependent increase in incidence in postmenopausal women compared to younger females. Regarding the treatment strategy, there was an increase in application of locking plates. The data implicate a typical fragility fracture related age and gender distribution for distal fibula fractures.

Why Insufficiency Fractures are Rarely Found in the Cervical Spine, Even with Osteoporosis

INTRODUCTION

The human bone structure changes with an increase in age. Both material and structural properties affect bone strength. Despite the ageing of society, however, hardly any data are available on these parameters for elderly individuals. Therefore, in the present study, cancellous bone cylinders were taken from the center of each vertebral body (C3 to L5) and examined with regard to bone volume fraction, trabecular thickness, separation, number of trabeculae, cross-linking, connectivity density and degree of anisotropy.

MATERIAL AND METHODS

Samples were obtained from 440 body donors using a Jamshidi needle and analysed using microcomputed tomography. Existing deformities, fractures and bone mineral density of each vertebra were recorded by quantitative computed tomography.

RESULTS

With regard to the microcomputed tomography parameters, statistically significant differences were found between the different sections of the vertebrae: the trabeculae of the cervical vertebrae were significantly thicker and more closely spaced than in the thoracic and lumbar vertebrae. The bone volume fraction was significantly higher in this spinal segment, as was the connection density and the number of trabeculae and cross-links. In addition, the degree of anisotropy was significantly lower in the cervical vertebrae than in the other spinal segments. With regard to quantitative computed tomography, there was a significantly higher bone mineral density in the cervical vertebrae.

CONCLUSION

Even with osteoporosis, cervical vertebrae fracture significantly later than thoracic and lumbar vertebrae due to their unique microarchitecture and higher density. Thus, the cervical vertebrae has specific properties.

Similar Clinical Outcome in Locking and Conventional Plate Osteosynthesis for the Treatment of AO 44-B2 Ankle Fractures

INTRODUCTION

Biomechanical studies have proved that locking plates have better primary stability besides versatility regarding fracture pattern while reducing bone contact and bridging the gap, whereas conventional nonlocking plates (plus lag screw) depend on bone-plate compression. The clinical benefit of locking plates over nonlocking plates remains unanswered, however. Therefore, this retrospective cohort study was set up to test the hypothesis that the use of locking plates for unstable ankle fractures will result in fewer re-displacements, superior bony healing, and functional and clinical outcomes better than observed in the nonlocking cohort.

METHODS

Bimalleolar ankle fractures (AO 44-B2) without syndesmotic injury treated with either a locking or a nonlocking plate were included. Groups were compared for complications, bone healing, secondary dislocation, progressions of osteoarthritis, and clinical outcome using patient-reported outcome measures.

RESULTS

Data revealed no clinical outcome differences (Olerud-Molander Ankle Score: nonlocking 88.2 ± 14.4, locking 88.8 ± 12.3, P = .69, robust two 1-sided test for equality (RTOST): P = .03; American Orthopaedic Foot and Ankle Score: nonlocking 91.2 ± 12.9, locking 91.8 ± 11.3, P = .96, RTOST: P = .04). Nevertheless, a significant postoperative progression of osteoarthritis was detected in both groups (P = .04). This was independent of implant (P = .16). Although difference was not significant, locking plates were preferred in older (P = .78) and sicker patients (P = .63) and in cases with severer osteoarthritis (P = .16), and were associated with a higher complication rate (P = .42) and secondary dislocation (nonlocking 9.4%, locking 18.2%; P = .42). Re-displacement, however, was not a compelling reason for revision.

CONCLUSIONS

The present study shows statistically significant equality of both types of implants. Contrary to our expectation, locking plates seemed to be associated with a higher risk for re-displacement. Overall, the use of either locking or nonlocking plates for unstable AO 44-B2 fractures is safe and successful despite significant progression of osteoarthritis.

LEVEL OF EVIDENCE

III, Retrospective observational cohort study.

The Dietary and Non-Dietary Management of Osteoporosis in Adult-Onset Celiac Disease: Current Status and Practical Guidance

Impaired bone mineral density (BMD) is a frequent complication of adult-onset celiac disease (CeD). This is usually due to malabsorption of nutrients, changes in bone metabolism in association with inflammation, and to a lesser extent, decreased overall physical health and mobility. This review aims to highlight the current status concerning surveillance, prevention, and treatment strategies for bone disease in CeD. A practical guidance on these matters is suggested. The available published research on the prevention and treatment of decreased BMD in relation to CeD is scarce. In general, publications were based on expert opinions or extrapolation from studies on postmenopausal women or inflammatory bowel disease. Optimal dietary treatment and an adequate supply of calcium and vitamin D are the cornerstones for the reduction in fracture risk in patients with CeD. In adults with low BMD or fragility fractures, CeD needs to be considered and specifically approached. When osteoporosis is documented, start treatment with an antiresorptive agent; these agents are proven to result in a long-term reduction in fracture risk in high-risk individuals. However, there are some important differences between the management of male and female patients, particularly premenopausal women, that need to be addressed. In patients with persisting diarrhea and malabsorption, parenteral medications may be preferable. Future research specifically focusing on celiac disease and the associated disorders in bone mineralization is mandatory to provide evidence-based recommendations in this field.

Effect of obesity on fragility fractures, BMD and vitamin D levels in postmenopausal women. Influence of type 2 diabetes mellitus

AIMS

To see the effects of obesity on risk fracture, bone density (BMD), and vitamin D levels in a group of postmenopausal women, and consider how comorbid type 2 diabetes mellitus (T2DM) modifies them.

METHODS

679 postmenopausal women were grouped into obese and non-obese. Obese women were grouped into those with T2DM and those without. 25(OH)-vitamin D, PTH and BMD were measured, and prevalent fragility fractures were gathered.

RESULTS

Obese women had higher prevalence of T2DM, than non-obese women. Levels of 25(OH)-vitamin D were lower and those of PTH higher in obese women, BMD values were higher in obese women. Diabetic-obese women had a higher prevalence of non-vertebral fractures than non-diabetic-obese. Multivariate logistic regression model showed association of fragility fractures with age, total hip BMD, BMI and T2DM. Obese women have higher BMD and lower 25(OH)-vitamin D values (and higher PTH) than non-obese, without diabetes.

CONCLUSIONS

T2DM confers an increased risk of non-vertebral fractures in postmenopausal obese women.

Insuffizienzfrakturen der Wirbelsäule in Abhängigkeit von der spongiösen Knochendichte

Hintergrund

Das Risiko für osteoporotische Insuffizienzfrakturen (Fx) am Achsenskelett steigt mit zunehmender Abnahme der Knochendichte, wobei sich thorakal und thorakolumbal eine Häufung findet. Um die unterschiedliche Verteilung von Fx entlang der Wirbelsäule (WS) besser zu verstehen, wurden morphologische und osteodensitometrische Untersuchungen mittels Computertomographie (CT) in den verschiedenen WS-Abschnitten durchgeführt. Zudem war zu klären, ob die bei CT-Untersuchungen aus anderen Indikationen gefunden Hounsfield-Einheiten (HE) mit der Knochendichte korrelieren und Anlass für eine osteologische Diagnostik sein könnten.

Material und Methoden

Von 26 Körperspenden wurden die gesamten WS in einem Plexiglas-Wasser-Phantom fixiert und mittels hochauflösende Spiral-CT analysiert. Zusätzlich erfolgte die Messung der CT-morphologischen Spongiosadichte in HE von C3 bis S2 (624 Wirbelkörper). Der Knochenmineralgehalt (KMG, mg/ml) wurde ermittelt und zur Abschätzung einer Osteoporose (OPO) herangezogen.

Ergebnisse

Bei allen WS lag eine OPO vor. Bei einem KMG unterhalb von 60 mg/ml fanden sich signifikant vermehrte Sinterungsfrakturen im thorakalen und thorakolumbalen Bereich. Osteoporotische Insuffizienzfrakturen im HWS-Bereich fanden sich insgesamt nicht. Die Spongiosadichte war signifikant höher in den zervikalen (Median 188,6 HE) als in den lumbalen (Median 63,6 HE) und sakralen (Median 25,5 HE) Wirbelkörpern aller untersuchten WS.

Schlussfolgerung

Ein KMG-Verlust der Wirbelkörperspongiosa führt zu einem erhöhten Fx-Risiko, welches sich auch bei den verwendeten WS findet. Jedoch wird im zervikalen Bereich ein scheinbarer Schwellenwert für das Auftreten von Sinterungsfrakturen nicht unterschritten. Einen Schwellenwert für HE zu finden, wäre für die klinische Praxis relevant.

Physical Therapist Management of Patients With Suspected or Confirmed Osteoporosis: A Clinical Practice Guideline From the Academy of Geriatric Physical Therapy

A clinical practice guideline on physical therapist management of patients with suspected or confirmed osteoporosis was developed by a volunteer guideline development group (GDG) that was appointed by the Academy of Geriatric Physical Therapy (APTA Geriatrics). The GDG consisted of an exercise physiologist and 6 physical therapists with clinical and methodological expertise. The guideline was based on a systematic review of existing clinical practice guidelines, followed by application of the ADAPTE methodological process described by Guidelines International Network for adapting guidelines for cultural and professional utility. The recommendations contained in this guideline are derived from the 2021 Scottish Intercollegiate Guideline Network (SIGN) document: Management of Osteoporosis and the Prevention of Fragility Fractures. These guidelines are intended to assist physical therapists practicing in the United States, and implementation in the context of the US health care system is discussed.

Prevalence, Characteristics, and Associated Risk Factors of Wrist Fractures in Americans Above 50: The Cross-Sectional NHANES Study

SUMMARY

By analyzing data from NHANES, we aimed to evaluate the prevalence, characteristics, and associated factors of wrist fractures in Americans aged 50 and above.

INTRODUCTION

Wrist fractures, whose prevalence increases with age, are one of the most common fractures in the United States. However, epidemiological studies on the prevalence of wrist fractures of certain ages were limited.

METHODS

The data of Americans aged 50 or above from 2013-2014 and 2017-2018 in NHANES were extracted and analyzed.

RESULTS

The prevalence of wrist fractures among Americans whose age was 50 or above was 12%, which was similar between men and women (men 12.8% vs. women 11.4%, p = 0.267). Among those who had experienced their first wrist fracture, 17.8% of the population experienced a second wrist fracture. The top two causes of the first wrist fracture were a fall from a standing height (56%) or a hard fall (34.8%). The prevalence of wrist fractures was higher in men than in women (13.7% versus 8.7%, p = 0.023) aged < 60, but higher in women than in men aged ≥ 60 (11.8% versus 14.3%, p = 0.007). Multivariate analysis showed that obesity, frequent drinking, current smoking, high serum phosphate level, non-Hispanic white women, and osteoporosis were independently associated with wrist fractures. Stratified by race, osteoporosis, frequent drinking, and high serum phosphate level were risk factors for wrist fractures in all races. As for Mexican Americans, non-Hispanic whites, and other races including multi-racial, current smoking was a risk factor of wrist factures. Furthermore, obesity was positively associated with wrist fractures in Mexican Americans, other Hispanics, and non-Hispanic whites.

CONCLUSION

The prevalence of wrist fractures in Americans aged 50 and above was 12%. Falling from a standing height was the main cause of the first wrist fracture. Frequent drinking, current smoker, high serum phosphate level, osteoporosis, obesity, and non-Hispanic women were more likely to experience wrist fractures.

Prediction of an Imminent Fracture After an Index Fracture - Models Derived From the Frisbee Cohort

Patients who sustain a fracture are at greatest risk of recurrent fracture during the next 2 years. We propose three models to identify subjects most at risk of an imminent fracture, according to fracture site (any fracture, major osteoporotic fracture [MOF] or central). They were constructed using data of the prospective Frisbee cohort, which includes 3560 postmenopausal women aged 60 to 85 years who were followed for at least 5 years. A total of 881 subjects had a first incident validated fragility fracture before December 2018. Among these, we validated 130 imminent fractures occurring within the next 2 years; 79 were MOFs, and 88 were central fractures. Clinical risk factors were re-evaluated at the time of the index fracture. Fine and Gray proportional hazard models were derived separately for each group of fractures. The following risk factors were significantly associated with the risk of any imminent fracture: total hip bone mineral density (BMD) (p < 0.001), a fall history (p < 0.001), and comorbidities (p = 0.03). Age (p = 0.05 and p = 0.03, respectively) and a central fracture as the index fracture (p = 0.04 and p = 0.005, respectively) were additional predictors of MOFs and central fractures. The three prediction models are presented as nomograms. The calibration curves and the Brier scores based on bootstrap resampling showed calibration scores of 0.089 for MOF, 0.094 for central fractures, and 0.132 for any fractures. The predictive accuracy of the models expressed as area under the receiver operating characteristic (AUROC) curve (AUC) were 0.74 for central fractures, 0.72 for MOFs, and 0.66 for all fractures, respectively. These AUCs compare well with those of FRAX and Garvan to predict the 5- or 10-year fracture probability. In summary, five predictors (BMD, age, comorbidities, falls, and central fracture as the incident fracture) allow the calculation with a reasonable accuracy of the imminent risk of fracture at different sites (MOF, central fracture, and any fracture) after a recent sentinel fracture. © 2021 American Society for Bone and Mineral Research (ASBMR).

Bariatric surgery and skeletal health: A narrative review and position statement for management by the European Calcified Tissue Society (ECTS)

CONTEXT

Numerous studies have demonstrated detrimental skeletal consequences following bariatric surgery.

METHODS

A working group of the European Calcified Tissue Society (ECTS) performed an updated review of existing literature on changes of bone turnover markers (BTMs), bone mineral density (BMD), and fracture risk following bariatric surgery and provided advice on management based on expert opinion.

LITERATURE REVIEW

Based on observational studies, bariatric surgery is associated with a 21-44% higher risk of all fractures. Fracture risk is time-dependent and increases approximately 3 years after bariatric surgery. The bariatric procedures that have a malabsorptive component (including Roux-en-Y Gastric bypass (RYGB) and biliopancreatic diversion (BPD)) have clearly been associated with the highest risk of fracture. The extent of high-turnover bone loss suggests a severe skeletal insult. This is associated with diminished bone strength and compromised microarchitecture. RYGB was the most performed bariatric procedure worldwide until very recently, when sleeve gastrectomy (SG) became more prominent. There is growing evidence that RYGB is associated with greater reduction in BMD, greater increase in BTMs, and higher risk of fractures compared with SG but RCTs on optimal management are still lacking.

EXPERT OPINION

In all patients, it is mandatory to treat vitamin D deficiency, to achieve adequate daily calcium and protein intake and to promote physical activity before and following bariatric surgery. In post-menopausal women and men older than 50 years, osteoporosis treatment would be reasonable in the presence of any of the following criteria: i) history of recent fragility fracture after 40 years of age, ii) BMD T-score ≤ -2 at hip or spine, iii) FRAX score with femoral neck BMD exceeding 20% for the 10-year major osteoporotic fracture probability or exceeding 3% for hip fracture. Zoledronate as first choice should be preferred due to intolerance of oral formulations and malabsorption. Zoledronate should be used with caution due to hypocemia risk. It is recommended to ensure adequate 25-OH vitamin D level and calcium supplementation before administering zoledronate.

CONCLUSIONS

The bariatric procedures that have a malabsorptive component have been associated with the highest turnover bone loss and risk of fracture. There is a knowledge gap on osteoporosis treatment in patients undergoing bariatric surgery. More research is necessary to direct and support guidelines.

Associations of overweight, obesity and osteoporosis with ankle fractures

BACKGROUND

Studies exploring risk factors for ankle fractures in adults are scarce, and with diverging conclusions. This study aims to investigate whether overweight, obesity and osteoporosis may be identified as risk factors for ankle fractures and ankle fracture subgroups according to the Danis-Weber (D-W) classification.

METHODS

108 patients ≥40 years with fracture of the lateral malleolus were included. Controls were 199 persons without a previous fracture history. Bone mineral density of the hips and spine was measured by dual-energy x-ray absorptiometry, and history of previous fracture, comorbidities, medication, physical activity, smoking habits, body mass index and nutritional factors were registered.

RESULTS

Higher body mass index with increments of 5 gave an adjusted odds ratio (OR) of 1.30 (95% confidence interval (CI) 1.03-1.64) for ankle fracture, and an adjusted OR of 1.96 (CI 0.99-4.41) for sustaining a D-W type B or C fracture compared to type A. Compared to patients with normal bone mineral density, the odds of ankle fracture in patients with osteoporosis was 1.53, but the 95% CI was wide (0.79-2.98). Patients with osteoporosis had reduced odds of sustaining a D-W fracture type B or C compared to type A (OR 0.18, CI 0.03-0.83).

CONCLUSIONS

Overweight increased the odds of ankle fractures and the odds of sustaining an ankle fracture with possible syndesmosis disruption and instability (D-W fracture type B or C) compared to the stable and more distal fibula fracture (D-W type A). Osteoporosis did not significantly increase the odds of ankle fractures, thus suffering an ankle fracture does not automatically warrant further osteoporosis assessment.

Unilateral cervical spinal cord injury induces bone loss and metabolic changes in non-human primates (Macaca fascicularis)

BACKGROUND/OBJECTIVE

The deleterious effects of chronic spinal cord injury (SCI) on the skeleton in rats, especially the lower extremities, has been proved previously. However, the long-term skeletal changes after SCI in non-human primates (NHP) have been scarcely studied. This study aimed to evaluate the bone loss in limbs and vertebrae and the bone metabolic changes in NHP after unilateral cervical spinal cord contusion injury.

METHODS

Twelve Macaca fascicularis were randomly divided into the SCI (n=8) and the Sham (n=4) groups. The SCI models were established using hemi-contusion cervical spinal cord injury on fifth cervical vertebra (C5), and were further evaluated by histological staining and neurophysiological monitoring. Changes of bone microstructures, bone biomechanics, and bone metabolism markers were assessed by micro-CT, micro-FEA and serological kit.

RESULTS

The NHP hemi-contusion cervical SCI model led to consistent unilateral limb dysfunction and potential plasticity in the face of loss of spinal cord. Furthermore, the cancellous bone mass of ipsilateral humerus and radius decreased significantly compared to the contralateral side. The bone volume fraction of humerus and radius were 17.2% and 20.1% on the ipsilateral while 29.0% and 30.1% on the contralateral respectively. Similarly, the thickness of the cortical bone in the ipsilateral forelimbs was significantly decreased, as well as the bone strength of the ipsilateral forelimbs. These changes were accompanied by diminished concentration of osteocalcin and total procollagen type 1 N-terminal propeptide (t-P1NP) as well as increased level of β-C-terminal cross-linking telopeptide of type 1collagen (β-CTX) in serological testing.

CONCLUSIONS

The present study demonstrated that hemi-SCI induced loss of bone mass and compromised biomechanical performance in ipsilateral forelimbs, which could be indicated by both muscle atrophy and serological changes of bone metabolism, and associated with a consistent loss of large-diameter cells of sensory neurons in the dorsal root ganglia.

THE TRANSLATIONAL POTENTIAL OF THIS ARTICLE

Our study, for the first time, demonstrated the bone loss in limbs and vertebrae as well as the bone metabolic changes in non-human primates after unilateral spinal cord injury (SCI). This may help to elucidate the role of muscle atrophy, serological changes and loss of sensory neurons in the mechanisms of SCI-induced osteoporosis, which would be definitely better compared with rodent models.

High-impact exercise stimulated localised adaptation of microarchitecture across distal tibia in postmenopausal women

We provided evidence that a 6-month regular hopping exercise intervention can increase trabecular number and possibly trabecular volume fraction of the distal tibia. Our novel localised analysis demonstrated region-specific changes, predominantly in the anterior region, in postmenopausal women.

INTRODUCTION

The localisation of bone remodelling and microarchitectural adaptation to exercise loading has not been demonstrated previously in vivo in humans. The aim of this study is to assess the feasibility of using 3D image registration and high-resolution peripheral quantitative computed tomography (HR-pQCT) to investigate the effect of high-impact exercise on human trabecular bone variables and remodelling rate across the distal tibia.

METHODS

Ten postmenopausal women were recruited for 6-month unilateral hopping exercises, with HR-pQCT scans taken of both exercise leg (EL) and control leg (CL) for each participant before and after the intervention. A 3D image registration was used to ensure measurements were taken at the same region. Short-term reproducibility tests were conducted prior to the assessment using identical setup. The results were assessed comparing CL and EL, and interaction (time × leg) using a two-way repeated measures analysis of variance (RM-ANOVA).

RESULTS

Across the whole tibia, we observed significant increases in trabecular number (Tb.N) (+ 4.4%) and trabecular bone formation rate (tBFR) (3.3%), and a non-significant increase in trabecular bone volume fraction (BV/TV) (+ 1%) in the EL. Regional resorption was higher in the CL than the EL, with this difference being statistically significant at the lateral tibia. In the EL, tBFR was significantly higher in the anterior region than the medial but a trabecular bone resorption rate (tBRR) showed no significant regional variation. Conversely in the CL, both tBFR and tBRR were significantly higher in the anterior and lateral than the medial region.

CONCLUSION

We demonstrated that it was possible to detect exercise-related bone adaptation with 3D registration of HR-pQCT scan data. Regular hopping exercise increased Tb.N and possibly BV/TV across the whole distal tibia. A novel finding of the study was that tBFR and tBRR responses to loading were localised: changes were achieved by formation rate exceeding resorption rate in the exercise leg, both globally and at the anterior region where turnover was greatest.

TRIAL REGISTRATION

clinicaltrials.gov : NCT03225703.

The different correlations between obesity and osteoporosis after adjustment of static mechanical loading from weight and fat free mass

OBJECTIVES

To explore complex correlations between obesity (OB) and osteoporosis (OP) after adjustment of static mechanical loading from weight and fat free mass (FFM).

METHODS

A total of 3749 Chinese aged ≥65 years were selected from our ongoing cohort study. OB indices and bone mineral density (BMD) were measured for each subject. Linear regression analyses were performed to explore the correlations between OB indices and OP under three adjustment models (unadjusted, adjusted with weight and adjusted with FFM).

RESULTS

Under no adjustment, three general obesity indices (body mass index: BMI, fat mass: FM, and percentage FM: PFM) were positively associated with BMD at three skeletal sites (P<0.001) in the regression analyses. However, after the adjustment with weight, these associations were mostly significant but reverse i.e., negatively in direction. After adjustment with FFM, the three indices were still positively and significantly (P<0.001) associated with BMD but regression coefficients were smaller compared to the unadjusted associations. Similar associations were observed for central adiposity and lower limb adiposity indices.

CONCLUSIONS

The combined relation of OB to OP due to the physiological factors secreted from adipose tissues and the static mechanical loading from FM is positive in direction.

Differential Risk of Incident Fractures Depending on Intensity and Frequency of Physical Activity According to Cognitive Status: A Nationwide Longitudinal Study

Background: Previous studies have demonstrated an increased risk of fractures in subjects with various degrees of cognitive impairments. Recently, there has been growing recognition of the vital effect of physical activity (PA) on delay and prevention of fractures in older adults.

Objectives: This study aimed to evaluate the optimal intensity and frequency of PA needed to prevent fractures in cognitively preserved older adults (CP), participants with subjective cognitive decline (SCD), and dementia patients using a large-scale nationwide cohort study.

Methods: Data from a nationwide health screening program for individuals at the transitional age of 66 years were used in this study. A total of 968,240 subjects was enrolled, followed from 2007 to 2014, and classified as CP (n = 759,874), SCD (n = 195,365), or dementia group (n = 13,001). Adjusted hazard ratios (aHRs) by demographic and known risk factors for fractures were evaluated to identify the impact of various frequency and intensity PA on the occurrence of hip, vertebral, and limb fractures.

Results: In CP participants, the most noticeable reduction of hip and vertebral fracture risk was shown in those performing vigorous-intensity PA at least three times per week. In the SCD group, the risk decrement in hip and vertebral fractures was most prominent in subjects who performed multiple-intensity PAs at least three times a week regardless of intensity. In the dementia group, only high-frequency walking and high-frequency & multiple-intensity PA decreased the risk of hip fractures compared with absence of PA.

Conclusion: These findings suggest a role for various PA intensity and frequency levels to prevent hip and vertebral fractures according to cognitive status. Further study is needed to validate the effects of PA intensity and frequency proposed in this study on fractures according to cognitive status.

Osteoprotective Effects of Loganic Acid on Osteoblastic and Osteoclastic Cells and Osteoporosis-Induced Mice

Osteoporosis is a common disease caused by an imbalance of processes between bone resorption by osteoclasts and bone formation by osteoblasts in postmenopausal women. The roots of Gentiana lutea L. (GL) are reported to have beneficial effects on various human diseases related to liver functions and gastrointestinal motility, as well as on arthritis. Here, we fractionated and isolated bioactive constituent(s) responsible for anti-osteoporotic effects of GL root extract. A single phytochemical compound, loganic acid, was identified as a candidate osteoprotective agent. Its anti-osteoporotic effects were examined in vitro and in vivo. Treatment with loganic acid significantly increased osteoblastic differentiation in preosteoblast MC3T3-E1 cells by promoting alkaline phosphatase activity and increasing mRNA expression levels of bone metabolic markers such as Alpl, Bglap, and Sp7. However, loganic acid inhibited osteoclast differentiation of primary-cultured monocytes derived from mouse bone marrow. For in vivo experiments, the effect of loganic acid on ovariectomized (OVX) mice was examined for 12 weeks. Loganic acid prevented OVX-induced bone mineral density loss and improved bone structural properties in osteoporotic model mice. These results suggest that loganic acid may be a potential therapeutic candidate for treatment of osteoporosis.

Gastric Bypass But Not Sleeve Gastrectomy Increases Risk of Major Osteoporotic Fracture: French Population-Based Cohort Study

The objective of this work was to investigate the risk of major osteoporotic fracture (MOF; hip, proximal humerus, wrist and distal forearm, and clinical spine) in bariatric surgery patients versus matched controls. Bariatric surgery is associated with an increase in fracture risk. However, it remains unclear whether the same degree of fracture risk is associated with sleeve gastrectomy, which has recently surpassed gastric bypass. Records from the French National Inpatient database were used from 2008 to 2018. Bariatric surgery patients, aged 40 to 65 years, with BMI ≥40 kg/m² , hospitalized between January 1, 2010 and December 31, 2014, were matched to one control (1:1) by age, sex, Charlson comorbidity index, year of inclusion, and class of obesity (40 to 49.9 kg/m² versus ≥50 kg/m² ). We performed a Cox regression analysis to assess the association between the risk of any MOF and, respectively, (i) bariatric surgery (yes/no) and (ii) type of surgical procedure (gastric bypass, gastric banding, vertical banded gastroplasty, and sleeve gastrectomy) versus no surgery. A total of 81,984 patients were included in the study (40,992 in the bariatric surgery group, and 40,992 matched controls). There were 585 MOFs in the surgical group (2.30 cases per 1000 patient-year [PY]) and 416 MOFs in the matched controls (1.93 cases per 1000 PY). The risk of MOF was significantly higher in the surgical group (hazard ratio [HR] 1.22; 95% CI, 1.08-1.39). We observed an increase in risk of MOF for gastric bypass only (HR 1.70; 95% CI, 1.46-1.98) compared with the matched controls. In patients aged 40 to 65 years, gastric bypass but not sleeve gastrectomy or the other procedures increased risk of major osteoporotic fractures. © 2020 American Society for Bone and Mineral Research.

Low-trauma ankle fractures in Brazil: secular trends in patients over 50 years old from 2004 to 2013

PURPOSE

The most common sites of low-energy trauma fractures are the femur, vertebra, humerus, and forearm. Ankle fractures have significant morbidity and high costs for surgical procedure. Forearm fractures are common nonvertebral fractures. Forearm fractures are classified as fragility fractures and predictive for fractures at other sites, although do not allow osteoporosis diagnosis. It is controversial whether ankle fractures are osteoporosis fractures.

METHODS

Retrospective observational study, with secular trend analysis, in patients over 50 years old admitted in the Brazilian Public Health System, from 2004 to 2013. We collected hospitalization data according to the ICD-10 for low-trauma ankle and forearm fractures. Fracture rate was calculated according to gender, age, and geographic region, performed linear regression analysis, and estimated fracture rates for 2030. Comparison of ankle and forearm rates was also performed, grouping them in 3-year block. ANOVA test was used to compare each block.

RESULTS

Ankle fracture rate was 21.39 fractures per 100,000 inhabitants, 23.98 in females and 18.49 in males. Fracture rates were higher in the South and Southeast regions. In absolute numbers, although ankle fracture rate increased with age, there was a significant decrease in the population over 80 years old. Data showed stabilization in ankle fractures from 2004 to 2013, in women and men. In 3-year block analysis, men had higher ankle fracture rates than forearm. However, in women, forearm rates were higher than ankle.

CONCLUSION

Our data suggest that ankle fractures in men would be considered as a sentinel fracture with a similar clinical impact of forearm fracture.

Bone and skeletal muscle changes in oldest-old women: the role of physical inactivity

BACKGROUND

Alterations in bone and muscle parameters related to advanced aging and physical inactivity have never been investigated in oldest-old women.

AIMS

To investigate the impact of physical inactivity on bone mineral density (BMD) and body composition at the systemic and regional levels in oldest-old (> 75 years old) women. We hypothesized that, further to aging, alterations in bone and body composition parameters are exacerbated in the locomotor limbs that have experienced physical inactivity.

METHODS

Whole-body and regional (lower limbs and trunk) BMD and fat-free soft tissue mass (FFSTM) were measured by means of dual-energy X-ray absorptiometry in 11 oldest-old wheelchair-bound women (OIW), 11 oldest-old mobile women (OMW), and 11 young healthy women (YW), all matched for weight (± 10 kg), height (± 10 cm).

RESULTS

Whole-body BMD was reduced by 15% from YW to OMW and 10% from OMW to OIW. Whole-body FFSTM was also reduced from YW to OIW (- 13%). Lower limb BMD was progressively reduced among YW, OMW and OIW (- 23%). Similarly, lower limb FFSTM was reduced among YW (12,816 ± 1797 g), OMW (11,999 ± 1512 g) and OIW (10,037 ± 1489 g). Trunk BMD was progressively reduced among YW, OMW and OIW (- 19%), while FFSTM was similar among the three groups ~ 19801 g.

CONCLUSIONS

The results of the present study suggest that the alterations in bone and body composition parameters are exacerbated in the physical inactive oldest-old. These negative effects of physical inactivity are not confined to the locomotor limbs, and a systemic decline of bone and muscle parameters are likely associated with the physical inactivity.

Biomechanics of Osteoporotic Fracture Fixation

PURPOSE OF REVIEW

Fractures of osteoporotic bone in elderly individuals need special attention. This manuscript reviews the current strategies to provide sufficient fracture fixation stability with a particular focus on fractures that frequently occur in elderly individuals with osteoporosis and require full load-bearing capacity, i.e., pelvis, hip, ankle, and peri-implant fractures.

RECENT FINDINGS

Elderly individuals benefit immensely from immediate mobilization after fracture and thus require stable fracture fixation that allows immediate post-operative weight-bearing. However, osteoporotic bone has decreased holding capacity for metallic implants and is thus associated with a considerable fracture fixation failure rate both short term and long term. Modern implant technologies with dedicated modifications provide sufficient mechanical stability to allow immediate weight-bearing for elderly individuals. Depending on fracture location and fracture severity, various options are available to reinforce or augment standard fracture fixation systems. Correct application of the basic principles of fracture fixation and the use of modern implant technologies enables mechanically stable fracture fixation that allows early weight-bearing and results in timely fracture healing even in patients with osteoporosis.

Does the Prediction Accuracy of Osteoporotic Fractures by BMD and Clinical Risk Factors Vary With Fracture Site?

Several clinical risk factors (CRFs) have been shown to predict the risk of fragility fractures independently of BMD, but their accuracy in the prediction of a particular fracture site has not been extensively studied. In this study based on longitudinal data from the FRISBEE cohort (Fracture Risk Brussels Epidemiological Enquiry), we evaluated if CRFs are specific for sites of incident osteoporotic fractures during follow‐up. We recruited 3560 postmenopausal women, aged 60 to 85 years, from 2007 to 2013, and surveyed yearly for the occurrence of fragility fractures during 6.2 years (median). We analyzed the association between CRFs included in the FRAX (fracture risk assessment tool) model or additional CRFs (falls, sedentary lifestyle, early untreated menopause, diabetes, use of selective serotonin reuptake inhibitors or proton pump inhibitors) and the first incident validated major osteoporotic fracture (MOF; n = 362; vertebra, hip, shoulder, and wrist) or other major fractures (n = 74; ankle, pelvis/sacrum, elbow, knee, long bones). Uni‐ and multivariate analyses using the Cox proportional hazards model were used. For MOFs considered together, the risk of fracture was highly associated in uni‐ and multivariate analyses (p<0.01) with osteoporosis (T‐score < −2.5), prior fracture, age, BMD (assessed by DXA), and fall history (HR 2.34, 1.82,1.71, 1.38, and 1.32, respectively). For each site analyzed separately, prior OF, age, smoking, and total hip BMD remained independent predictors for hip fractures (HR 5.72, 3.98, 3.10, 2.32, and 1.92, respectively); osteoporosis, age, prior OF, glucocorticoids, and spine BMD for vertebral fracture (HR 2.08, 1.87, 1.78, 1.76, and 1.45, respectively); osteoporosis, prior OF, and femoral neck BMD (HR 1.83, 1.60, and 1.56, respectively) for wrist fracture; osteoporosis, prior OF, and spine BMD (HR 2.48, 1.78, and 1.31, respectively) for shoulder fracture; prior OF and diabetes (HR 2.62 and 2.03) for other major fractures. Thus, a prior fracture and BMD were the best predictors of fracture risk at any site. Other CRFs have a weaker predictive value, which is a function of the site of a future fracture. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Obesity and Bone Health Revisited: A Mendelian Randomization Study for Koreans

Epidemiologic studies have replicated positive associations between obesity and bone health, but their mechanisms are still debatable. We aimed to scrutinize an association between bone health and obesity using genetic instrumental variables (IVs) with the distinction of general versus abdominal obesity. We selected independent IVs of body mass index (BMI) and BMI-adjusted waist circumference (aWC, a proxy of a central fat distribution) by combining novel genomewide searches from the Korean Genome Epidemiology Study (KoGES) consortium and existing reports. We evaluated the associations of obesity indices with bone health measures for weight-bearing and non-weight-bearing bones, applying standard Mendelian randomization analyses. The IVs for BMI and aWC selected from KoGES cohort studies (n = 14,389) explained its own trait only, negating the mutual correlation at the phenotypic level. Two-stage least squares analyses using an independent cohort study (n = 2507, mean age = 44.4 years, men = 44.3%) showed that BMI but not aWC was positively associated with bone mineral density (BMD for weight-bearing bones: 0.063 ± 0.016 g/cm² per one standard deviation increase in BMI), implying the fat distribution might be neutral. The association was weaker for non-weight-bearing bones (BMI on BMD: 0.034 ± 0.011 g/cm² ), and for postmenopausal women the association was absent. Obesity increased both bone area and bone mineral content (BMC) to a lesser degree, but the increase in BMC was not evident for menopausal women. When we stratified the weight into lean body mass and fat mass, the increase in BMD was more evident for lean body mass, and fat mass showed a beneficial role only for men and premenopausal women. Our findings suggest that bone health might gain little from obesity, if any, through its added weight, and other means to prevent bone loss would be essential for postmenopausal women. © 2019 American Society for Bone and Mineral Research.

Effects of Leptin on the Skeleton

Leptin originates in adipocytes, including those in bone marrow, and circulates in concentrations 20 to 90 times higher than those in the cerebrospinal fluid. It has direct anabolic effects on osteoblasts and chondrocytes, but it also influences bone indirectly, via the hypothalamus and sympathetic nervous system, via changes in body weight, and via effects on the production of other hormones (e.g., pituitary). Leptin's role in bone physiology is determined by the balance of these conflicting effects. Reflecting this inconsistency, the leptin-deficient mouse has reduced length and bone mineral content of long bones but increased vertebral trabecular bone. A consistent bone phenotype in human leptin deficiency has not been established. Systemic leptin administration in animals and humans usually exerts a positive effect on bone mass, and leptin administration into the cerebral ventricles usually normalizes the bone phenotype in leptin-deficient mice. Reflecting the role of the sympathetic nervous system in mediating the central catabolic effects of leptin on the skeleton, β-adrenergic agonists and antagonists have major effects on bone in mice, but this is not consistently seen in humans. The balance of the central and peripheral effects of leptin on bone remains an area of substantial controversy and might vary between species and according to other factors such as body weight, baseline circulating leptin levels, and the presence of specific pathologies. In humans, leptin is likely to contribute to the positive relationship observed between adiposity and bone density, which allows the skeleton to respond appropriately to changes in soft tissue mass.

Lower bone mineral density in older female endurance skiers - a cross-sectional, observational study

Background

Physical activity (PA) is generally beneficial for bone health, but the effect of high levels of PA over many years, in older women, is unknown.

Methods

T-score from Dual-energy X-ray absorptiometry (DXA), and self-reported baseline characteristics were recorded for 24 female, cross-country-skiing-competitors, aged 68-76 years, from the Birkebeiner Ageing Study. Data from 647 women in the same age range from the Tromso-6 population study, with recorded DXA findings, were used for comparison.

Results

The athletes reported a median(range) of 9(1-34) participations in the 54 km, yearly ski-race, indicating long-term PA. They also reported more moderate and high levels of PA than women in the general population (52% vs. 12 and 30% vs. 0%, respectively). The athletes had lower body mass index (BMI) than the controls (mean BMI 21.7 vs 26.9 kg/m², p < 0.001). As many as 22/24(92%) of the athletes and 477/647(74%) of the controls had a low bone mineral density (BMD) (T-score < - 1), p 0.048, Pearson chi square test. Odds ratio (OR) of low BMD was 3.9 in athletes vs. controls (p 0.048, logistic regression), but adjusting for BMI largely diminished the effect estimate, which was no longer statistically significant (aOR 1.81, p 0.432). The proportion of self-reported fractures was the same in the two groups.

Conclusions

This pilot study suggests that long-term, high levels of PA are associated with low bone mineral density in older women, and the finding might be due to differences in BMI. Despite the lower bone mineral density the athletes did not report more fractures.

Risk of Subsequent Fragility Fractures Observed After Low-Trauma Ankle Fractures

While fragility fractures (FFs) are one of the strongest predictors of subsequent osteoporotic fractures, it remains unclear whether low-trauma ankle fractures have this ability. The aim of the study was to identify the characteristics of patients with low-trauma ankle FFs who develop subsequent FFs. The OPTIMUS initiative is a strategy to improve osteoporosis treatment post-FF in orthopedic clinics. FRAX scores without BMD (FRAX-BMI) were calculated at time of inclusion. Recurrent FFs were recorded over a 48-month follow-up. All FFs were X-ray-confirmed. A total of 265 patients with initial ankle FF were included (190 women; mean age 62.8 ± 9.6 years), of whom 15 developed new FFs. Patients with ankle FFs had longer time until recurrence and lower 2-year incidence of recurrent FFs (3.2%) compared with those having wrist FFs (9.0%) or other initial FFs (9.6%), and 4-year incidence rates of 6.2, 13.4, and 15.3%, respectively (log-rank test, p = 0.001). With an ankle FF at inclusion, recurrent FFs were more frequent in patients with previous FF (6.2 per 100 patient-years; p < 0.01) or high-risk FRAX-BMI scores pre- or post-FF (2.4 or 2.0 per 100 patient-years, respectively; ns), compared to patients without any of these conditions (0.7 per 100 patient-years). Ankle FFs represent a clinical opportunity for identifying at-risk patients who should be targeted for treatment (previous FFs and/or high-risk FRAX). Because of mechanical factors and other contributors involved, ankle FFs themselves do not predict subsequent FFs overall, and their inclusion in FRAX-BMI risk calculation may thus not be warranted.

The relationship between objectively assessed physical activity and bone health in older adults differs by sex and is mediated by lean mass

Relationships between objectively assessed free-living physical activity (PA) and changes in bone health over time are poorly understood in older adults. This study suggests these relationships are sex-specific and that body composition may influence the mechanical loading benefits of PA.

INTRODUCTION

To investigate associations of objectively assessed PA and bone health in community-dwelling older adults.

METHODS

This secondary analysis of a subset of the Tasmanian Older Adult Cohort study included participants with PA assessed utilising ActiGraph GT1M accelerometers over 7 days (N = 209 participants, 53% female; mean ± SD age 64.5 ± 7.2 years). Steps/day and PA intensity were estimated via established thresholds. Bone mineral content (BMC) was acquired at the total hip, lumbar spine, legs and whole body by DXA at baseline and approximately 2.2 years later. Relationships between PA and BMC were assessed by multivariable linear regression analyses adjusted for age, smoking status, height and total lean mass.

RESULTS

Men with above-median total hip BMC completed significantly less steps per day, but there was no significant difference in PA intensity compared with those with below-median BMC. There were no significant differences in PA in women stratified by median BMC. In women, steps/day were positively associated with leg BMC (B = 0.178; P = 0.017), and sedentary behaviour was negatively associated with leg BMC (- 0.165; 0.016) at baseline. After adjustment for confounders including lean mass and height, higher sedentary behaviour at baseline was associated with declines in femoral neck BMC (- 0.286; 0.011) but also with increases in pelvic BMC (0.246; 0.030) in men and increases in total hip BMC (0.215; 0.032) in women, over 2.2 years. No other significant longitudinal associations were observed after adjustment for body composition.

CONCLUSIONS

Associations of accelerometer-determined sedentary behaviour and PA with bone health in older adults differ by sex and anatomical site and are mediated by body composition.

A meta-analysis of the association between body mass index and risk of vertebral fracture

We conducted a meta-analysis of prospective studies to assess the association between BMI and incident vertebral fracture. We found that as body mass index (BMI) increases, the risk of vertebral fracture decreases in men, but not in women, suggesting possible gender differences in the relationship of BMI with risk of vertebral fracture.

INTRODUCTION

Recent evidence suggests that the relationship between BMI and fracture risk may be site-specific. We conducted a systematic review and meta-analysis of prospective studies to investigate the association between BMI and risk of incident vertebral fracture.

METHODS

PubMed and Embase were searched for relevant articles published from inception through February 15, 2017. Extracted relative risks (RR) from the prospective studies were pooled using random-effects meta-analysis.

RESULTS

Six studies were included, with a total of 105,129 participants followed for 3 to 19 years. The pooled RR (95% confidence interval [CI]) for vertebral fracture per each standard deviation increase in BMI was 0.94 (95% CI = 0.80-1.10) with significant heterogeneity (I ² = 88.0%, p < 0.001). In subgroup analysis by gender, we found a significant inverse association between BMI and risk of vertebral fracture in men (RR = 0.85, 95% CI = 0.73-0.98, n = 25,617 participants) but not in women (RR = 0.98, 95% CI = 0.81-1.20, n = 79,512 participants). Across studies of women not adjusting for bone mineral density (BMD), there was no significant association between BMI and risk of vertebral fracture (RR = 0.91, 95% CI = 0.80-1.04, p = 0.18, n = 72,755 participants). However, BMI was associated with an increased risk of vertebral fracture in studies of women that adjusted for BMD (RR = 1.28, 95% CI = 1.17-1.40, p < 0.001, n = 6757 participants). Substantial heterogeneity was found among studies of women (I ² = 90.1%, p < 0.001), which was partly explained by the adjustment for BMD (adjusted R ² = 61%). We found no evidence of publication bias (p = 0.40).

CONCLUSIONS

In conclusion, our findings suggest that there might be gender differences in the relationship of BMI with risk of vertebral fracture. Further research is needed, including the assessment of other measures of adiposity, such as visceral adiposity, on the risk of vertebral fracture.

Management of Osteoporotic and Neuropathic Ankle Fractures in the Elderly

Purpose of Review

Treatment of osteoporotic and neuropathic ankle fractures in the elderly is challenging. The purpose of this paper is to review recent publications on this topic and to identify the optimal treatment for these fractures.

Recent Findings

Treatment consists of a variety of conservative or operative options all with advantages and disadvantages as described in this review. Little research has been published that specifically focuses on elderly patients with ankle fractures. Operative treatment has a high complication rate. Multiple comorbidities are predictors for complications.

Summary

An optimal treatment could not be distilled but based on the available literature, a general treatment algorithm is proposed. Since the elderly typically are accompanied by multiple comorbidities as well as impaired mobility, the physician should focus not only on treating the fractured ankle but also on the patient as a whole. Further research on this specific topic is needed.

Sex-specific association between obesity and self-reported falls and injuries among community-dwelling Canadians aged 65 years and older

This study investigated the relationship between body mass index (BMI) and falls among community-dwelling elderly. Results indicate that obesity is associated with increased falls and there appears to be a sex-specific difference with obese men at higher risk of falling. Obesity is identified as a risk factor for falls in men.

INTRODUCTION

The prevalence of falls, fall-related injuries, and obesity has increased over the last decade. The objectives of this study were to investigate sex-specific association and dose-response relationship between BMI and falls (and related injuries) among community-dwelling elderly.

METHODS

Our study sample consisted of 15,860 adults aged 65 years or older (6399 men and 9461 women) from the 2008-2009 Canadian Community Health Survey-Healthy Aging (CCHS-HA). Falls, fall-related injuries, and BMI measures were self-reported. For both sex, dose-response curves presenting the relationship between BMI, falls, and fall-related injuries were first examined. Thereafter, multivariate logistic regression analyses were also performed to investigate these relationships after adjustment for potentially confounding variables.

RESULTS

Of women, 21.7 % reported a fall and 16.9 % of men. The dose-response relationship between BMI and prevalence of falls showed that underweight and obese individuals reported falling more than normal and overweight individuals; this being more apparent in men than women. Finally, the dose relationship between BMI and prevalence of fall-related injuries showed that only obese men seem more likely to have sustained a fall-related injury. Results from the multivariate analysis showed that obesity in men was significantly associated with higher odds of falling odds ratio (OR) 1.33 (1.04-1.70) and was not significantly associated with higher odds of fall-related injuries OR 1.10 (0.66-1.84) over a 12-month period compared to normal weight men. For women, obesity was not significantly associated with higher fall prevalence OR 0.99 (0.79-1.25) and fall-related injuries OR 0.71 (0.51-1.00).

CONCLUSION

Obesity is associated with self-reported falls, and there appears to be a sex-specific difference in elderly persons.

Muscle mass is associated with incident fracture in postmenopausal women: The OFELY study

The relationships between body composition and bone mineral density are well established but the contribution of body composition to the risk of fracture (Fx) has rarely been evaluated prospectively. We analyzed the risk of Fx by body composition in 595 postmenopausal women (mean age 66±8years) from a longitudinal cohort study (Os des Femmes de Lyon). We assessed the risk of the first incident fragility Fx according to body composition obtained from whole-body DXA: abdominal visceral (VFAT) and subcutaneous fat mass (SFAT), total body fat mass (FM), lean mass index (LMI) and appendicular skeletal muscle mass index (ASMI). During a median [IQ] follow-up of 13.1years [1.9], 138 women sustained a first incident Fx, including 85 women with a major osteoporotic Fx (MOP Fx: hip, clinical spine, humerus or wrist). After adjustment for age, women who sustained Fx had lower BMI (-4%, p=0.01), LMI (-6%, p=0.002) and ASMI (-3%, p=0.003), compared with women without Fx. After adjustment for age, prevalent Fx, physical activity, incident falls and FN BMD, each SD increase of baseline values of LMI and ASMI was associated with decreased Fx risk with adjusted hazard ratios of 0.76 for both of p≤0.02. Those associations were similar after accounting for the competing risk of death. VFAT and SFAT were associated with Fx risk in the multivariate model only for MOP Fx and the association did not persist after consideration of competing mortality. We conclude that lean mass and appendicular muscle mass indexes are associated with the risk of fracture in postmenopausal women independently of BMD and clinical risk factors.

Association of Body Mass Index With the Pattern of Surgically Treated Ankle Fractures Using Two Different Classification Systems

The present retrospective cohort study assessed the association of body mass index (BMI) with the pattern of ankle fractures using 2 classifications systems. Of the 1011 consecutive patients who underwent surgery for ankle fractures in 2 hospitals from January 2009 to December 2011, 837 had a classifiable fracture according to 1 of 2 classification systems and complete information available for covariates. The association of BMI, adjusted for age, sex, corticosteroid use, diabetes, and smoking status with having a more proximal fibula fracture (Weber class A to C) and an increasing number of malleoli involved (uni-, bi-, or trimalleolar) was assessed using multivariable ordered logistic regression analysis. The mean age of the patients was 50.9 ± 16.9 years, and 461 (55%) were female. On multivariable analysis, BMI and male sex were associated with having a more proximal fibula fracture using the Weber classification, with an odds ratio (OR) of 1.07 (95% confidence interval [CI] 1.04 to 1.11; p < .001) per 1 kg/m² increase and OR of 2.96 (95% CI 2.13 to 4.11; p < .001) compared with female sex, respectively. Age was not associated with this fracture classification. In an analysis of uni-, bi-, and trimalleolar fractures, age per 10 years showed higher odds (OR 1.24, 95% CI 1.14 to 1.36; p < .001) and male sex lower odds compared with female sex (OR 0.36, 95% CI 0.27 to 0.48; p < .001) of having trimalleolar fractures than uni- or bimalleolar fractures. An increasing BMI did not seem to be a risk factor, although an inverse U-shaped relationship was seen between quintiles of BMI and the OR of having trimalleolar versus uni- or bimalleolar fractures. Corticosteroid use, diabetes, and smoking status were not significantly associated with the pattern of the ankle fractures using either classification system. In conclusion, an increasing BMI and male sex were risk factors for proximal fibula fractures, and female sex and age were risk factors for bi- and trimalleolar fractures.