Age-related hip fractures in men: clinical spectrum and short-term outcomes

Enhancement of Hip X-ray with Convolutional Autoencoder for Increasing Prediction Accuracy of Bone Mineral Density

It is very important to keep track of decreases in the bone mineral density (BMD) of elderly people since it can be correlated with the risk of incidence of major osteoporotic fractures leading to fatal injuries. Even though dual-energy X-ray absorptiometry (DXA) is the one of the most precise measuring techniques used to quantify BMD, most patients have restricted access to this machine due to high cost of DXA equipment, which is also rarely distributed to local clinics. Meanwhile, the conventional X-rays, which are commonly used for visualizing conditions and injuries due to their low cost, combine the absorption of both soft and bone tissues, consequently limiting its ability to measure BMD. Therefore, we have proposed a specialized automated smart system to quantitatively predict BMD based on a conventional X-ray image only by reducing the soft tissue effect supported by the implementation of a convolutional autoencoder, which is trained using proposed synthesized data to generate grayscale values of bone tissue alone. From the enhanced image, multiple features are calculated from the hip X-ray to predict the BMD values. The performance of the proposed method has been validated through comparison with the DXA value, which shows high consistency with correlation coefficient of 0.81 and mean absolute error of 0.069 g/cm2.

A novel approach for evaluating bone mineral density of hips based on Sobel gradient-based map of radiographs utilizing convolutional neural network

Osteoporosis, which is a common disorder associated with low bone mineral density (BMD), is one of the primary reasons for hip fracture. It not only limits mobility, but also makes the patient suffer from pain. Unlike traditional methods, which require both expensive equipment and long scanning times, this study aims to develop a novel technique employing a convolutional neural network (CNN) directly on radiographs of the hips to evaluate BMD. To construct the dataset, X-ray photographs of lower limbs and dual-energy X-ray absorptiometry (DXA) results of the hips of patients were collected. The core of this research is a deep learning-based model that was trained using the pre-processed X-rays images of 510 hips as the input data and the BMD values obtained from DXA as the standard reference. To improve performance quality, the radiographs of the hips were processed with a Sobel algorithm to extract the gradient magnitude maps, and an ensemble artificial neural network which analyses the outputs of CNN models corresponding to three Singh sites and biological parameters was utilized. The superior performance of the proposed method was confirmed by the high correlation coefficient of 0.8075 (p<0.0001) of the BMD measured by DXA in a total of 150 testing cases, with only 0.12 s required for applying the computing configuration to a single X-ray image.

Associated Factors of Bone Mineral Density and Osteoporosis in Elderly Males

BACKGROUND

Low bone mineral density and osteoporosis is prevalent in elderly subjects. This study aimed to determine the associated factors of bone mineral density and osteoporosis in elderly males.

METHODS

All participants of the Amirkola health and ageing project cohort aged 60 years and older entered the study. Bone mineral density at femoral neck and lumbar spine was assessed by the dual energy X-ray absorptiometry (DXA) method. Osteoporosis was diagnosed by the international society for clinical densitometry criteria and the association of bone mineral density and osteoporosis with several clinical, demographic and biochemical parameters. Multiple logistic regression analysis was used to determine independent associations.

RESULTS

A total of 553 patients were studied and 90 patients (16.2%) had osteoporosis at either femoral neck or lumbar spine. Diabetes, obesity, metabolic syndrome, overweight, and quadriceps muscle strength > 30 kg, metabolic syndrome, abdominal obesity and education level were associated with higher bone mineral density and lower prevalence of osteoporosis, whereas age, anemia, inhaled corticosteroids and fracture history were associated with lower bone mineral density and higher prevalence of osteoporosis (P = 0.001). After adjustment for all covariates, osteoporosis was negatively associated only with diabetes, obesity, overweight, and QMS > 30 kg and positively associated with anemia and fracture history. The association of osteoporosis with other parameters did not reach a statistical level.

CONCLUSIONS

The findings of the study indicate that in elderly males, diabetes, obesity and higher muscle strength was associated with lower prevalence of osteoporosis and anemia, and prior fracture with higher risk of osteoporosis. This issue needs further longitudinal studies.

Osteoporotic hip fractures: 10-year review in a Singaporean hospital

PURPOSE

To review records of 2702 patients with osteoporotic hip fractures in a Singaporean hospital.

METHODS

Medical records of 1905 women and 797 men, aged 50 to 112 (median, 78) years, who were admitted to a Singaporean hospital with an osteoporotic hip fracture (ICD9 820) between January 2000 and December 2010 were reviewed.

RESULTS

Female patients were significantly older than male patients (p<0.0005). The trend for the median patient age over the 10-year period has increased significantly in women (r=0.826, p=0.002) but not in men. Of the hip fractures, 49.4% were femoral neck fractures and 50.6% were intertrochanteric/ basicervical fractures. The rate of intertrochanteric/ basicervical fractures was higher in men than women (61.2% vs. 46.1%, p<0.0005). Increased age, ischaemic heart disease, Parkinson's disease, and being Malay or Caucasian or Sikh were more likely to have intertrochanteric/basicervical fractures than femoral neck fractures. Femoral neck fractures were usually treated with hemiarthroplasty (68.8%), cancellous screw fixation (20.6%), and conservative methods (20.5%), whereas intertrochanteric/basicervical fractures were usually treated with dynamic hip screw fixation (76.3%) and conservative methods (15.6%). 84 women and 26 men sustained a subsequent osteoporotic hip fracture on the contralateral side after a median interval of 2 (range, 0-8) years. 11 of these 110 patients were already on osteoporosis medication.

CONCLUSION

The rate of osteoporotic hip fractures has increased, particularly among women, over the 10- year period. The rate of intertrochanteric/basicervical fractures was higher in men than women.

Dependence for basic and instrumental activities of daily living after hip fractures

The objective of the study is to determine basic activities of daily living (Barthel Index) and instrumental activities of daily living (Lawton-Brody Index) before and after hip fracture. Follow-up study of patients (n=100) with hip fracture, operated at Complejo Hospitalario Universitario de A Coruña (Spain). Period January/2009-December/2011. Demographic characteristic of the patients, Charlson Index, Glomerular filtration rate, Barthel index, Lawton index, type of proximal femur fracture and surgical treatment delay were recorded. Multivariate regression was performed. Informed patient consent and ethical review approval were obtained. Before fracture were independent for activities of daily living (ADL) a 38.0%, at 90 days were 15.4%. The Barthel index score decreased from 75.2±28.2 to 56.5±31.8) (p<0.0001). If we consider the age, gender, comorbidity (Charlson index), renal function, fracture type and surgical delay objectify the only independent variable to predict dependency effect is age. If we also consider the Barthel score objectify the variable that significantly modifies that score at 90 days is the baseline value of the index. The prevalence of independence for instrumental activities of daily living (IADL) at the baseline moment is 11% and at 90 days is decreased to 2.2%. There is a decrease in the independence effect in all activities. The variable predictor of independence for all activities after taking into consideration age, sex, comorbidity, fracture type, surgical delay and renal function is the baseline score of the Barthel and Lawton index.

Fracture risk among older men: osteopenia and osteoporosis defined using cut-points derived from female versus male reference data

SUMMARY

We explored the effect of using male and female reference data in a male sample to categorise areal bone mineral density (BMD). Using male reference data, a large proportion of fractures arose from osteopenia, whereas using female reference data shifted the fracture burden into normal BMD.

INTRODUCTION

The purpose of this study was to describe fracture risk associated with osteopenia and osteoporosis in older men, defined by areal BMD and using cut-points derived from male and female reference data.

METHODS

As part of the Geelong Osteoporosis Study, we followed 619 men aged 60-93 years after BMD assessments (performed 2001-2006) until 2010, fracture, death or emigration. Post-baseline fractures were radiologically confirmed, and proportions of fractures in each BMD category were age-standardised to national profiles.

RESULTS

Based on World Health Organization criteria, and using male reference data, 207 men had normal BMD at the femoral neck, 357 were osteopenic and 55 were osteoporotic. Using female reference data, corresponding numbers were 361, 227 and 31. During the study, 130 men died, 15 emigrated and 63 sustained at least one fracture. Using male reference data, most (86.5 %) of the fractures occurred in men without osteoporosis on BMD criteria (18.4 % normal BMD, 68.1 % osteopenia). The pattern differed when female reference data were used; while most fractures arose from men without osteoporosis (88.2 %), the burden shifted from those with osteopenia (34.8 %) to those with normal BMD (53.4 %).

CONCLUSIONS

Decreasing BMD categories defined increasing risk of fracture. Although men with osteoporotic BMD were at greatest risk, they made a relatively small contribution to the total burden of fractures. Using male reference data, two-thirds of the fractures arose from men with osteopenia. However, using female reference data, approximately half of the fractures arose from those with normal BMD. Using female reference data to define osteoporosis in men does not appear to be the optimal approach.

Causes, consequences, and treatment of osteoporosis in men

Men undergo gradual bone loss with aging, resulting in fragile bones. It is estimated that one in five men will suffer an osteoporotic fracture during their lifetime. The prognosis for men after a hip fracture is very grim. A major cause is reduction of free testosterone. Many other factors result in secondary osteoporosis, including treatment for other diseases such as cancer and diabetes. Patients should be screened not only for bone density but also assessed for their nutritional status, physical activity, and drug intake. Therapy should be chosen based on the type of osteoporosis. Available therapies include testosterone replacement, bisphosphonates, and nutritional supplementation with calcium, vitamin D, fatty acids, and isoflavones, as well as certain specific antibodies, like denosumab and odanacatib, and inhibitors of certain proteins.

Meta-analysis: excess mortality after hip fracture among older women and men

BACKGROUND

Although an increased risk for death after hip fracture is well established, whether this excess mortality persists over time is unclear.

PURPOSE

To determine the magnitude and duration of excess mortality after hip fracture in older men and women.

DATA SOURCES

Electronic search of MEDLINE and EMBASE for English and non-English articles from 1957 to May 2009 and manual search of article references.

STUDY SELECTION

Prospective cohort studies were selected by 2 independent reviewers. The studies had to assess mortality in women (22 cohorts) or men (17 cohorts) aged 50 years or older with hip fracture, carry out a life-table analysis, and display the survival curves of the hip fracture group and age- and sex-matched control groups.

DATA EXTRACTION

Survival curve data and items relevant to study validity and generalizability were independently extracted by 2 reviewers.

DATA SYNTHESIS

Time-to-event meta-analyses showed that the relative hazard for all-cause mortality in the first 3 months after hip fracture was 5.75 (95% CI, 4.94 to 6.67) in women and 7.95 (CI, 6.13 to 10.30) in men. Relative hazards decreased substantially over time but did not return to rates seen in age- and sex-matched control groups. Through use of life-table methods, investigators estimated that white women having a hip fracture at age 80 years have excess annual mortality compared with white women of the same age without a fracture of 8%, 11%, 18%, and 22% at 1, 2, 5, and 10 years after injury, respectively. Men with a hip fracture at age 80 years have excess annual mortality of 18%, 22%, 26%, and 20% at 1, 2, 5, and 10 years after injury, respectively.

LIMITATIONS

Cohort studies varied, sometimes markedly, in size, duration of observation, selection of control populations, ascertainment of death, and adjustment for comorbid conditions. Only published data that displayed findings with survival curves were examined. Publication bias was possible.

CONCLUSION

Older adults have a 5- to 8-fold increased risk for all-cause mortality during the first 3 months after hip fracture. Excess annual mortality persists over time for both women and men, but at any given age, excess annual mortality after hip fracture is higher in men than in women.

PRIMARY FUNDING SOURCE

Fund for Scientific Research and Willy Gepts Foundation, Universitair Ziekenhuis Brussel.

Predictors and Sequelae of Fractures in the Elderly: The Canadian Study of Health and Aging (CSHA)

The objective of this study was to describe the incidence, type, risk factors, and sequelae of fractures experienced by community-dwelling elderly Canadians. Data are from the Canadian Study of Health and Aging (CSHA), a longitudinal cohort study, collected in three waves: baseline (1991), wave 2 (1996), and wave 3 (2001). In CSHA-2 (1996), fractures were reported by 3.7 per cent of men and 7.5 per cent of women; in CSHA-3 (2001), by 2.9 per cent of men and 7.3 per cent of women. The distribution of fracture types was similar for men and women. Risk factors for women were increased age, history of fracture, and regular alcohol use; for men, stroke, arthritis, and lack of independent bathing. Walkers or wheelchairs were needed by over 30 per cent of those with any lower body fracture. One third of subjects with any fracture and over 50 per cent with femur fractures reported moderate or severe pain. It is concluded that elderly Canadians are at high risk for fractures, and older women are at most risk. Pain and mobility problems were common sequelae. The need for primary and secondary prevention of these age-related events is paramount.

Meta-analysis: excess mortality after hip fracture among older women and men

BACKGROUND

Although an increased risk for death after hip fracture is well established, whether this excess mortality persists over time is unclear.

PURPOSE

To determine the magnitude and duration of excess mortality after hip fracture in older men and women.

DATA SOURCES

Electronic search of MEDLINE and EMBASE for English and non-English articles from 1957 to May 2009 and manual search of article references.

STUDY SELECTION

Prospective cohort studies were selected by 2 independent reviewers. The studies had to assess mortality in women (22 cohorts) or men (17 cohorts) aged 50 years or older with hip fracture, carry out a life-table analysis, and display the survival curves of the hip fracture group and age- and sex-matched control groups.

DATA EXTRACTION

Survival curve data and items relevant to study validity and generalizability were independently extracted by 2 reviewers.

DATA SYNTHESIS

Time-to-event meta-analyses showed that the relative hazard for all-cause mortality in the first 3 months after hip fracture was 5.75 (95% CI, 4.94 to 6.67) in women and 7.95 (CI, 6.13 to 10.30) in men. Relative hazards decreased substantially over time but did not return to rates seen in age- and sex-matched control groups. Through use of life-table methods, investigators estimated that white women having a hip fracture at age 80 years have excess annual mortality compared with white women of the same age without a fracture of 8%, 11%, 18%, and 22% at 1, 2, 5, and 10 years after injury, respectively. Men with a hip fracture at age 80 years have excess annual mortality of 18%, 22%, 26%, and 20% at 1, 2, 5, and 10 years after injury, respectively.

LIMITATIONS

Cohort studies varied, sometimes markedly, in size, duration of observation, selection of control populations, ascertainment of death, and adjustment for comorbid conditions. Only published data that displayed findings with survival curves were examined. Publication bias was possible.

CONCLUSION

Older adults have a 5- to 8-fold increased risk for all-cause mortality during the first 3 months after hip fracture. Excess annual mortality persists over time for both women and men, but at any given age, excess annual mortality after hip fracture is higher in men than in women.

PRIMARY FUNDING SOURCE

Fund for Scientific Research and Willy Gepts Foundation, Universitair Ziekenhuis Brussel.

[High morbid-mortability and reduced level of osteoporosis diagnosis among elderly people who had hip fractures in São Paulo City]

OBJECTIVE

To know the morbid-mortality following an osteoporotic hip fracture in elderly patients living in São Paulo.

PATIENTS AND METHODS

This study evaluated prospectively all patient over 60 years admitted in 2 school-hospitals in the city of São Paulo in a following 6-month period due to a osteoporotic proximal femur fracture. All of them filled up the Health Assessment Questionnaire (HAQ) and had their chart reviewed. After 6 months they were re-interviewed. Linear regression analysis was utilized to determine the factors related to functional ability.

RESULTS

56 patients were included (mean age 80.7 +/- 7.9 years old, 80.4% females). After the 6-month follow up the mortality rate was 23.2%. Only 30% of the patients returned to their previous activities, and 11.6% became totally dependent. Factors related to worse functional ability after fracture were HAQ before fracture, institutionalization after fracture and age (r(2) 0.482). The diagnosis of osteoporosis was informed only by 13.9% of them, and just 11.6% received any treatment for that.

CONCLUSION

Our results showed the great impact of these fractures on mortality and in the functional ability of these patients. Nevertheless, many of our physicians do not inform the patients about the diagnosis of osteoporosis and, consequently, the treatment of this condition is jeopardized.

Risk Factors for the Development of Osteoporosis and Osteoporotic Fractures Among Older Men

Objective.

Osteoporotic fractures are associated with significant morbidity and mortality particularly among older men. However, there is little information regarding risk factors among this population. The aims of our study were to determine risk factors for osteoporosis and fragility fractures and the predictive value of bone mineral density (BMD) measurements for development of fragility fractures in a cohort of elderly Caucasian and African American men.

Methods.

We evaluated 257 men aged 70 years or older for risk factors for osteoporosis and fragility fractures using a detailed questionnaire and BMD assessment. Exclusion criteria included conditions known to cause osteoporosis such as hypogonadism and chronic steroid use, current treatment with bisphosphonates, bilateral hip arthroplasties, and inability to ambulate independently.

Results.

Age, weight, weight loss, androgen deprivation treatment, duration of use of dairy products, exercise, and fracture within 10 years prior to study entry were associated with osteoporosis (p ≤ 0.05). Fragility fractures were associated with duration of use of dairy products, androgen deprivation treatment, osteoporosis, and history of fracture within 10 years prior to BMD assessment (p ≤ 0.05). There were some differences in risk factors between the Caucasian and African American populations, suggesting that risk factors may vary between ethnic groups.

Conclusion.

Although men with osteoporosis had a higher rate of fractures, the majority of fractures occurred in men with T-scores > −2.5 standard deviations below the mean, suggesting that factors other than BMD are also important in determining risk.

Sex steroids and bone turnover markers in men with symptomatic vertebral fractures

Sex steroids play an important role in the maintenance of bone density in men and women, but the circulating, biologically active unbound fraction is influenced by the concentration of sex hormone binding globulin (SHBG). SHBG increases with advancing age in men and leads to a reduction in serum free testosterone and oestradiol, which may then affect bone turnover, bone mineral density (BMD) and the risk of fractures. We have therefore measured total and unbound sex steroids, SHBG, bone turnover markers and BMD in 57 men with symptomatic low trauma vertebral fractures and 57 age-matched male control subjects. Fasting blood and urine samples were collected from all subjects, who also underwent BMD measurement of the lumbar spine and hip. Serum testosterone, oestradiol, SHBG, bone specific alkaline phosphatase (bone ALP) and urine free deoxypyridinoline/creatinine ratio (fDPD/Cr) were measured. Free sex steroid concentrations were calculated using their ratio with SHBG and albumin and bioavailable testosterone was measured using radioimmunoassay. The two groups were then compared and regression models developed to determine the best predictors of BMD and fracture. Men with vertebral fractures had significantly lower weight and BMD at all sites than control subjects (p<0.0001). Serum total testosterone and oestradiol did not differ between the two groups, but calculated free androgen and free oestradiol indices were lower in the fracture group than the control subjects (p=0.04), due to higher SHBG (46.6 versus 36.1 nmol/L: p=0.005). The men with vertebral fractures had significantly higher mean bone ALP (15.8 versus 11.8 microg/L: p=0.002) and fDPD/Cr (5.5 versus 4.0 nmol/mmol: p=0.03). Stepwise multiple regression analysis in both fracture and control groups found body weight to be the best predictor of BMD. In the fracture group weight predicted between 19.7 and 30.7% of the variance in BMD and in control subjects this was between 12.3 and 13.2%. SHBG contributed to the model for hip BMD in the fracture group alone, so that weight and SHBG together accounted for 32 to 42.9% of the variance. A model combining BMD at the spine, total femur and femoral neck with height loss best predicted fracture. In conclusion, men with symptomatic vertebral fractures have higher SHBG and lower calculated free sex steroid indices, increased bone turnover and lower BMD. Whilst body weight was the best predictor of BMD, symptomatic vertebral fracture was best predicted by BMD and height loss.

Association of depressive symptoms with bone mineral density in older men: a population-based study

OBJECTIVE

Thirty percent of hip fractures occur in men; nevertheless, the determinants of osteoporosis in men are unclear.

METHODS

We assessed the association of ultrasound-derived bone mineral density (UD-BMD) with depressive symptoms in a population-based study. We assessed the association of 30-item Geriatric Depression Scale (GDS) score with the ultrasound-derived T-score, Z-score, and Stiffness index in all 306 subjects aged 75 + living in Tuscania (Italy).

RESULTS

In multivariable linear regression analysis, GDS was associated among men with the ultrasound-derived T-score (beta = -0.09; 95% CI = -0.15 to -0.03; p = 0.003), Z-score (beta = -0.07; 95% CI = -0.13 to -0.01; p = 0.032), and the Stiffness index (beta = -0.90; 95% CI = -1.64 to -0.16; p = 0.018) after adjusting for potential confounders. No significant associations were observed in women. In linear discriminant analysis, the GDS score cutoff that best predicted osteoporosis was >or=19. Participants with mild to severe depressive symptoms had threefold increased probability of having an ultrasound-derived T-score < -2.5.

CONCLUSIONS

Depressive symptoms are independently associated with all UD-BMD parameters. As depression is a common feature among older populations, and because subjects with depression are infrequent users of preventive services, older men with depression should be prompted to undergo screening for osteoporosis. Conversely, assessment for depression should be performed in older men with diagnosis of osteoporosis.

Computer-based screening of chest X-rays for vertebral compression fractures as an osteoporosis index in men

We evaluated the recognition of osteoporosis in the veteran male population through a computer-based review of chest X-ray (CXR) reports in the Veterans Affairs Northern California Health Care System database, looking for unrecognized vertebral fractures. All CXR reports between January 1, 2000 and December 31, 2001, were scanned for the terms "compression" or "wedg (where the "" indicates a wild card search encompassing such terms as "wedge" or "wedging")". During this time, 26,994 CXR examinations were performed on 18,069 patients. 22,494 (83.3% of the total) CXR examinations were done in 14,561 men >or=50 years of age. 780 CXR reports (3.5%) encompassing 664 men (4.5%) contained at least one key phrase suggesting osteoporosis. Three years later, 495 of these 664 men were still living. 99 of these (20%) had been diagnosed with osteoporosis, 72 (15%) had a dual-energy X-ray absorptiometry (DXA) scan, and 89 (18%) had ever been prescribed a bisphosphonate. Overall, only 126 (25%) men had chart documentation indicating some recognition by the provider of the abnormality reported on CXR. We conclude that a significant fraction of men >50 years old may have unrecognized osteoporosis severe enough to result in vertebral fracture. We conclude that computerized screening of CXR reports may represent an effective strategy to aid clinicians in identifying men at risk for further debilitating fractures.

Composição corporal de pacientes acamados por fraturas do quadril

As fraturas do quadril são a maior causa de hospitalização da terceira idade, e constituem um considerável encargo econômico e social. A taxa de mortalidade atual após um ano de fratura é acima de 33%, e o risco de morte é maior do quarto ao sexto mês após a fratura. O objetivo deste estudo foi de avaliar alterações na composição corporal de pacientes idosos, durante sua hospitalização por fraturas fêmur proximal, através de métodos antropométricos e análise dos valores fisiológicos de gasto energético. Foi realizado um estudo prospectivo utilizando-se 45 pacientes consecutivos com diagnóstico de fratura do quadril. Em todos os casos, foram obtidas medidas diretas e avaliações antropométricas indiretas baseadas em estimativas, nas primeiras 24 horas e repetidas após uma semana de admissão hospitalar. Após uma semana de internação houve diminuição da média do perímetro do braço (0,73 cm, p=0.0052) e da espessura da prega tricipital (1.41 mm, p=0.0181), sem haver modificação das outras variáveis estudadas. A avaliação antropométrica como um meio de se fazer um mapa da composição corporal, em conjunto com as estimativas indiretas sugeridas neste estudo, podem ajudar a determinar o estado nutricional e necessidades calóricas de pacientes idosos.

A new technique for cement augmentation of the sliding hip screw in proximal femur fractures

BACKGROUND

Fractures of the osteoporotic proximal femur are a significant source of mortality and morbidity in today's ageing population. Even with modern fixation techniques such as the sliding hip screw, a certain percentage of fixations will fail due to cut-out of the screw. This study presents a new method for augmenting hip screws with cement to reinforce the fixation.

METHODS

Unstable pertrochanteric fractures were created in paired osteoporotic cadaver femora (n=10). The fractures were fixed using either standard fixation techniques (dynamic hip screw), or using a dynamic hip screw augmented with cement. Cement was introduced using a customised jig to guide cement into a region superior to the screw in the femoral head. Cut-out resistance was assessed using a biaxial material testing machine, with loading applied in compression until failure.

FINDINGS

The new cement augmentation technique significantly improved the cut-out strength of the fixation (mean 42%; P=0.032). The failure mechanism for both groups was the same, with failure occurring through compression of the cancellous bone superior to the screw. The mean increase in temperature at the femoral neck was 3.7 degrees C in augmented bones, which is much lower than values previously reported for polymethylmethacrylate cements.

INTERPRETATION

Several benefits with this technique have emerged. The method is technically straightforward. The risk of cement penetration into the joint is reduced, and cement is targetted to the areas of the femoral head where it is most needed. The exothermic reaction is minimised by reducing the volume of cement used. The first clinical results are promising.

Osteoporosis, falls and exercise

Osteoporosis, a manifestation of bone atrophy that leads to great susceptibility to fractures, is a very important public health problem today because of its great morbidity, mortality and important economic repercussions. It is a problem that will tend to become more serious with the increase in the number of elderly persons. Bone mass is gained during adolescence, reaches a plateau during the third decade and remains stable until approximately age 50, after which a progressively gradual loss is observed. There is no real cure for osteoporosis, but a series of strategies can be used to reduce bone loss and improve bone mass. Osteoporosis has been considered a disease that accompanies the process of ageing; however, this fatalistic attitude should be discarded, as it is possible to correct and decrease the risk factors. Intervention strategies are based on three pillars: nutrition, physical activity and pharmacological agents. Physical activities and exercise programmes are important because they not only can counter the loss of bone mass but also improve neuromuscular capacity, maintaining and increasing strength and muscle mass, which can help to avoid falls and reduce their impact and consequences. The general principles that apply to any exercise programme also apply to preventing bone mass loss. They also can be applied to persons with osteoporosis. However, to understand the peculiarities of these programmes, the propensity for suffering fractures of these former groups should be kept in mind. Special care should be taken to avoid falls and injuries. Weight-bearing exercise and resistance training are recommended for the prevention programmes. Other activities such as tai-chi, dancing, gymnastic or callisthenic exercises can help to improve balance, gait and muscle coordination and diminish the risk of falling. These programmes should be complemented with postural education and a series of safety precautions.

Osteoporosis in the aging male: treatment options

In elderly women, loss in bone mass and micro-architectural changes are generally attributed to the onset of menopause. Men do not experience menopause, they do, however, experience age-related acceleration in bone loss and micro-architecture deterioration. The incidence of osteoporotic fractures in elderly men, just as in aged women, increases exponen-tially with age; the rise in men, however, is some 5-10 years later than in women. Up to 50% of male osteoporotics have no identifiable etiology; however elderly males have much higher likelihood of having an identifiable secondary cause than younger men. Therefore, clinical and laboratory evaluation of aged male osteoporotics must be thorough and should be aimed at identifying lifestyle or conditions contributing to bone loss and fragility. It is essential to identify and treat secondary causes and ensure adequate vitamin D and calcium intake before embarking upon treatment with pharmacological agents. The evidence from a limited number of trials suggests that bisphosphonates, especially alendronate and risedronate, are effective in improving BMD, and seem to be the treatments of choice in aged men with osteoporosis. In cases where bisphosphonates are contra-indicated or ineffective, teriparatide or alternatives such as strontium should be considered.

Osteoporosis in Men

With the prolongation of life expectancy, osteoporosis has become an increasing problem in the majority of developed countries worldwide. The paper discusses the frequency, pathogenesis, diagnostic criteria and treatment options for osteoporosis in men. Every third hip fracture occurs in men, and more than 11% of the male population over the age of 50 years suffer the fracture. Diagnostic tests for idiopathic osteoporosis are performed in men under 60 years of age without other potential risk factors of developing the disease. In the majority of cases, their low bone mineral density (BMD) is caused by a low peak bone mass. Secondary osteoporosis occurs in about 30 % of men, and involutionary osteoporosis developed in men over 60 years of age results from their decreased testosterone and IGF-1 levels. The study results showing that BMD levels in both sexes provide similar fracture risk information suggest that the existing diagnostic criteria for female osteoporosis can also be employed in men. It has been proved that biphosphonate and teriparitide therapy significantly increase BMD levels in men. The administration of androgens has been shown to be effective in men with hypogonadism, although their validity for patients with eugonadism has not yet been discussed. An improved knowledge of the bone metabolism and bone remodelling has recently opened the door to an extensive series of molecules that may play a key role in the treatment of male osteoporosis in the future.

The diagnosis and treatment of male osteoporosis: Defining, assessing, and preventing skeletal fragility in men

Male osteoporosis is associated with a significant burden in terms of morbidity, mortality, and economic cost. Despite recent advances in the understanding of the male osteoporotic syndrome, the evaluation and treatment of men suffering from osteoporosis remains a clinical challenge. In men with osteoporosis, it remains particularly critical to exclude underlying pathological causes as these are much more likely to be present than in women. There is increasing evidence that the approaches developed to diagnose and treat the disorder in women may be equally useful in men. The available evidence suggests that the anti-fracture efficacy of treatment with alendronate, risedronate, or teriparatide is similar in both sexes. Additional research is warranted to prospectively address the usefulness of BMD measurements to predict fracture risk, to identify those men who are likely to benefit the most from therapy, and to monitor individual responses to therapy.

Estradiol, testosterone, and the risk for hip fractures in elderly men from the Framingham Study

BACKGROUND

Low serum estradiol has been more strongly associated with low bone mineral density in elderly men than has testosterone, but its association with incident hip fracture is unknown. We examined whether low estradiol increases the risk for future hip fracture among men and explored whether testosterone levels influence this risk.

METHODS

We examined 793 men (mean age = 71 years) evaluated between 1981 and 1983, who had estradiol measures and no history of hip fracture, and followed until the end of 1999. Total estradiol and testosterone were measured between 1981 and 1983. Hip fractures were identified and confirmed through medical records review through the end of 1999. We created 3 groups of men based on estradiol levels and performed a Cox-proportional hazards model to examine the risk for incident hip fracture, adjusted for age, body mass index, height, and smoking status. We performed similar analyses based on testosterone levels, and then based on both estradiol and testosterone levels together.

RESULTS

There were 39 men who sustained an atraumatic hip fracture over follow-up. Incidence rates for hip fracture (per 1000 person-years) were 11.0, 3.4, and 3.9 for the low (2.0-18.1 pg/mL [7-67 pmol/L]), middle (18.2-34.2 pg/mL [67-125 pmol/L]), and high (> or =34.3 pg/mL [> or =126 pmol/L]) estradiol groups, respectively. With adjustment for age, body mass index, height, and smoking status, the adjusted hazard ratios for men in the low and middle estradiol groups, relative to the high group, were 3.1 (95% confidence interval [CI], 1.4-6.9) and 0.9 (95% CI, 0.4-2.0), respectively. In similar adjusted analyses evaluating men by their testosterone levels, we found no significant increased risk for hip fracture. However, in analyses in which we grouped men by both estradiol and testosterone levels, we found that men with both low estradiol and low testosterone levels had the greatest risk for hip fracture (adjusted hazard ratio: 6.5, 95% CI, 2.9-14.3).

CONCLUSION

Men with low estradiol levels are at an increased risk for future hip fracture. Men with both low estradiol and low testosterone levels seem to be at greatest risk for hip fracture.

Natural history and treatment of bone complications in prostate cancer

Bone metastases are highly prevalent in patients with prostate cancer, and they commonly present a therapeutic challenge. The natural history of prostatic bone metastases is characterized by skeletal morbidity, often producing distressing symptoms for individual patients and reducing patient autonomy and mobility. These bone metastases are usually radiologically osteoblastic, but there is also a strong osteolytic component as evidenced by marked increases in bone resorption markers. Malignant bone lesions can reduce the structural integrity of the skeleton, resulting in skeletal complications such as pathologic fracture, spinal cord compression, and severe bone pain, which adversely affect quality of life. Preclinical and clinical studies have provided insight into the pathophysiology of malignant bone disease from prostate cancer and suggest that bone-directed therapies, including radionuclides, endothelin-1 antagonists, and bisphosphonates, may provide both palliative and therapeutic benefits. Clinical investigations with these agents are underway in patients with prostate cancer to gain insight into the pathophysiology of bone metastases and to evaluate the role of bone-specific therapies in treating and preventing bone metastases.

Rationale for zoledronic acid therapy in men with hormone-sensitive prostate cancer with or without bone metastasis

Men with prostate cancer are at risk for bone loss and skeletal complications throughout the course of their disease. Bone loss is prevalent in many men with prostate cancer at initial diagnosis, and initiating androgen deprivation therapy results in accelerated bone resorption, leading to bone loss and an increased risk of fracture. These men are also at high risk for disease progression and bone metastases that can result in significant skeletal morbidity, including pathologic fracture, spinal cord compression, and debilitating bone pain requiring additional therapy. Excessive osteoclast activity plays a central role in the pathophysiology of bone disease at each stage of prostate cancer disease progression. Zoledronic acid, a highly potent inhibitor of osteoclast-mediated bone resorption, has increased bone mineral density in men receiving androgen deprivation therapy and is the only bisphosphonate that has shown statistically significant reductions in skeletal morbidity in patients with bone metastases from prostate cancer. Furthermore, preclinical evidence suggests that zoledronic acid has antitumor activity in prostate cancer models. Recently, a treatment algorithm was developed by the 3rd International Consultation on Prostate Cancer recommending the use of zoledronic acid for the prevention of skeletal complications in patients with bone metastases from prostate cancer, regardless of their hormone status, and for the prevention of treatment-induced bone loss in patients without evidence of bone metastases. According to this algorithm, zoledronic acid should be considered for the prevention of skeletal morbidity in patients with prostate cancer throughout their treatment continuum.

The decline of androgen levels in elderly men and its clinical and therapeutic implications

Aging in men is accompanied by a progressive, but individually variable decline of serum testosterone production, more than 20% of healthy men over 60 yr of age presenting with serum levels below the range for young men. Albeit the clinical picture of aging in men is reminiscent of that of hypogonadism in young men and decreased testosterone production appears to play a role in part of these clinical changes in at least some elderly men, the clinical relevancy of the age-related decline in sex steroid levels in men has not been unequivocally established. In fact, minimal androgen requirements for elderly men remain poorly defined and are likely to vary between individuals. Consequently, borderline androgen deficiency cannot be reliably diagnosed in the elderly, and strict differentiation between "substitutive" and "pharmacological" androgen administration is not possible. To date, only a few hundred elderly men have received androgen therapy in the setting of a randomized, controlled study, and many of these men were not androgen deficient. Most consistent effects of treatment have been on body composition, but to date there is no evidence-based documentation of clinical benefits of androgen administration to elderly men with normal or moderately low serum testosterone in terms of diminished morbidity or of improved survival or quality of life. Until the long-term risk-benefit ratio for androgen administration to elderly is established in adequately powered trials of longer duration, androgen administration to elderly men should be reserved for the minority of elderly men who have both clear clinical symptoms of hypogonadism and frankly low serum testosterone levels.

Quality of life, morbidity, and mortality after low trauma hip fracture in men

BACKGROUND

Osteoporotic hip fractures have been extensively studied in women, but they have been relatively ignored in men.

OBJECTIVE

To study the mortality, morbidity, and impact on health related quality of life of male hip fractures.

METHODS

100 consecutive men aged 50 years and over, with incident low trauma hip fracture, admitted to Royal Cornwall Hospital, UK during 1995-97, were studied. 100 controls were recruited from a nearby general practice. Mortality and morbidity, including health status assessed using the SF-36, were evaluated over a 2 year follow up period.

RESULTS

Survival after 2 years was 37% in fracture cases compared with 88% in controls (log rank test 62.6, df = 1, p = 0.0001). In the first year 45 patients died but only one control. By 2 years 58 patients but only 8 controls had died. Patients with hip fracture died from various causes, the most common being bronchopneumonia (21 cases), heart failure (9 cases), and ischaemic heart disease (8 cases). Factors associated with increased mortality after hip fracture included older age, residence before fracture in a nursing or residential home, presence of comorbid diseases, and poor functional activity before fracture. Patients with fracture were often disabled with poor quality of life. By 24 months 7 patients could not walk, 12 required residential accommodation, and the mean SF-36 physical summary score was 1.7SD below the normal standards.

CONCLUSIONS

Low trauma hip fracture in men is associated with a significant increase in mortality and morbidity. Impaired function before fracture is a key determinant of mortality after fracture.

The near absence of osteoporosis treatment in older men with fractures

The burden of osteoporotic fractures in older men is significant. The objectives of our study were to: (1) characterize older men with fractures associated with osteoporosis, (2) determine if medication treatment rates for osteoporosis are improving and (3) identify patient, healthcare benefit and utilization, and clinician characteristics that are significantly associated with treatment. This retrospective cohort study assessed 1,171 men aged 65 or older with any new fracture associated with osteoporosis between 1 January 1998 and 30 June 2001 in a non-profit health maintenance organization in the United States. Multiple logistic regression was used to evaluate pre-fracture factors for their association with osteoporosis treatment in the 6-month post-fracture period. The main outcome measure was pharmacologic treatment for osteoporosis in the 6 months after the index fracture. Subjects' average age was 76.7 years; 3.3% had a diagnosis of osteoporosis and 15.2% a diagnosis or medication associated with secondary osteoporosis. Only 7.1% of the study population and 16.0% of those with a hip or vertebral fracture received a medication for osteoporosis following the index fracture, and treatment rates did not improve over time. In the multivariate model, factors significantly associated with drug treatment were a higher value on the Charlson Comorbidity Index (odds ratio 1.26, 95% confidence interval 1.05-1.51), having an osteoporosis diagnosis (odds ratio 8.11, 95% confidence interval 3.08-21.3), chronic glucocorticoid use (odds ratio 5.37, 95% confidence interval 2.37-12.2) and a vertebral fracture (odds ratio 16.6, 95% confidence interval 7.8-31.4). Bone mineral density measurement was rare (n =13, 1.1%). Our findings suggest that there is under-ascertainment and under-treatment of osteoporosis and modifiable secondary causes in older men with fractures. Information systems merging diagnostic and treatment information can help delineate gaps in patient management. Interventions showing promise in other conditions should be evaluated to improve care for osteoporosis.

Male Osteoporosis

Osteoporosis is a common condition in men affecting approximately 2 million males in the US. Compared with women, osteoporosis develops later in life and the incidence of osteoporosis-related fractures is lower in men. The morbidity and mortality associated with osteoporotic fractures are much greater in men compared with women, and secondary causes of osteoporosis are more frequently (in approximately 50% of cases) identified in men compared with women with osteoporosis. Excessive alcohol consumption, glucocorticoid excess and hypogonadism are the most commonly identified causes. Primary osteoporosis in men has been linked to changes in sex steroid secretion, the growth hormone-insulin-like growth factor-1 (GH-IGF-1) axis and the vitamin D-parathyroid hormone (PTH) 25-hydroxyvitamin D [25(OH)D]-PTH system. Diagnosing osteoporosis in men is complicated by an ongoing debate on whether to use sex-specific reference values for bone mineral density (BMD) or female reference values. The International Society for Clinical Densitometry recommended using a T score of -2.5 or less of male reference values to diagnose osteoporosis in men who are > or =65 years of age. However, this definition is yet to be validated in terms of fracture incidence and prevalence. Ensuring adequate calcium and vitamin D intake is the cornerstone of any regimen aimed at preventing or treating osteoporosis in men. Bisphosphonates are currently the therapy of choice for treatment of male osteoporosis. A short course of parathyroid hormone (1-34) [teriparatide] may be indicated for men with very low BMD or in those in whom bisphosphonate therapy is unsuccessful. The use of testosterone-replacement therapy for the prevention and treatment of male osteoporosis remains controversial but likely to benefit osteoporotic men with evident hypogonadism.

Evidence from data searches and life-table analyses for gender-related differences in absolute risk of hip fracture after Colles' or spine fracture: Colles' fracture as an early and sensitive marker of skeletal fragility in white men

Based on data searches and life-table analyses, we determined the long-term (remaining lifetime) and short-term (10- and 5-year) absolute risks of hip fracture after sustaining a Colles' or spine fracture and searched for potential gender-related differences. In aging men, Colles' fractures carry a higher absolute risk for hip fracture than spinal fractures in contrast to women. These findings support the concept that forearm fracture is an early and sensitive marker of male skeletal fragility.

INTRODUCTION

Colles' fracture occurrence has been largely ignored in public health approaches to identify target populations at risk for hip fracture. The aim of this study was to estimate the long-term and short-term absolute risks of hip fracture after sustaining a Colles' or spine fracture and to search for potential gender-related differences in the relationship between fracture history and future fracture risk.

MATERIALS AND METHODS

To determine the long-term (remaining lifetime) and short-term (10- and 5-year) absolute risks of hip fracture, we applied life-table methods using U.S. age- and sex-specific hip fracture incidence rates, U.S. age-specific mortality rates for white women and men, pooled hazard ratios for mortality after Colles' and spine fracture, and pooled relative risks for hip fracture after Colles' and spine fracture, estimated from cohort studies by standard meta-analytic methods.

RESULTS

Our results indicate that the estimated remaining lifetime risks are dependent on age in both genders. In women, remaining lifetime risks increase until the age of 80 years, when they start to decline because of the competing probabilities of fracture and death. The same pattern is found in men until the age of 85 years, the increment in lifetime risk being even more pronounced. As expected, the risk of sustaining a hip fracture was found to be higher in postmenopausal women with a previous spine fracture compared with those with a history of Colles' fracture. In men, on the other hand, the prospective association between fracture history and subsequent hip fracture risk seemed to be strongest for Colles' fracture. At the age of 50, for example, the remaining lifetime risk was 13% in women with a previous Colles' fracture compared with 15% in the context of a previous spine fracture and 9% among women of the general population. In men at the age of 50 years, the corresponding risk estimates were 8%, 6%, and 3%, respectively. Similar trends were observed when calculating 5- and 10-year risks.

CONCLUSIONS

In aging men, Colles' fractures carry a higher absolute risk for hip fracture than spinal fractures in contrast to women. These findings support the concept that forearm fracture is an early and sensitive marker of male skeletal fragility. The gender-related differences reported in this analysis should be taken into account when designing screening and treatment strategies for prevention of hip fracture in men.

Skeletal Morbidity in Men with Prostate Cancer: Quality-of-Life Considerations throughout the Continuum of Care

OBJECTIVE

With current treatments, men usually survive many years after being diagnosed with prostate cancer. However, without supportive care, the systemic effects of prostate cancer and therapies such as androgen deprivation therapy (ADT) can undermine skeletal integrity, resulting in skeletal complications that may erode quality of life (QOL). Prostate cancer patients are at risk for fractures from cancer treatment-induced bone loss. In addition, they are also at risk for pathologic fractures, severe bone pain, and other sequelae from bone metastases, which almost invariably occur during the progression of prostate cancer. This review investigates the incidence and pathophysiology of bone loss and skeletal morbidity in prostate cancer patients and reviews available treatment options for maintaining skeletal health throughout the continuum of care for these patients.

METHODS

Studies were identified through MEDLINE searches, review of bibliographies of relevant articles, and review of abstracts from national meetings.

RESULTS

Several supportive care options are available to prevent generalized and localized bone loss, including calcium and vitamin D supplements and bisphosphonates. Oral calcium and vitamin D supplementation alone, however, appears to be insufficient to prevent bone loss during ADT. Zoledronic acid administered every 3 months during ADT or every 3 to 4 weeks for patients with bone metastases can reverse bone loss and reduce skeletal morbidity, respectively, in patients with prostate cancer.

CONCLUSIONS

Skeletal complications contribute to the erosion of QOL in prostate cancer patients. Palliative care can provide important benefits to these patients. Some agents, such as zoledronic acid, may provide skeletal health benefits throughout the course of prostate cancer progression. Further investigations of the QOL impact of these benefits are warranted.

Bone loss and the evolving role of bisphosphonate therapy in prostate cancer

Androgen deprivation therapy (ADT) can result in significant loss of bone mineral density (BMD) but to date, there are no prospective studies that document the true severity of bone loss and resulting fracture rates. In the general population, however, the incidence of low BMD is increasing in elderly men. Men suffer more morbidity and mortality from fractures associated with low BMD than women. Problems of underdiagnosis and undertreatment in men can be addressed with enhanced awareness of the risk factors for bone loss in men and the available treatment options. Guidelines for diagnosis of low BMD in women can probably be applied to men. Treatment options have not been studied as extensively in men. For men treated with ADT for prostate cancer, however, use of intravenous zoledronic acid at the initiation of ADT has been shown to prevent and even reverse bone loss. Although the routine use of bisphosphonates to prevent bone loss is not yet recommended, zoledronic acid is a logical choice of therapy in men who have low BMD at baseline or who develop bone loss during the course of therapy. In addition to its effects on BMD, zoledronic acid has also been shown to decrease skeletal morbidity in men with metastatic hormone-refractory prostate cancer. Whether zoledronic acid or other bisphosphonates might actually prevent or delay the development of bone metastases remains to be studied in randomized clinical trials.

Understanding treatments for bone loss and bone metastases in patients with prostate cancer: a practical review and guide for the clinician

Prostate cancer patients are at risk for developing bone loss and bone metastases. Clinicians prescribing ADT should appreciate the potential effects of ADT on BMD as well as the morbidity and mortality that can result from osteoporotic fractures. Measures to address the evaluation of patients and when to treat patients with significant bone loss have been discussed. Bisphosphonates effectively prevent loss of BMD in prostate cancer patients. Treatment of prostate cancer patients with established bone metastases with zoledronic acid should be considered strongly based on the results of the Saad study and other studies of patients with bone metastases with other malignancies. Zoledronic acid is approved by the US FDA for use in men with metastatic hormone-refractory prostate cancer and in the European Union for any patient with bone metastases, including prostate cancer patients,because of the beneficial impact of zoledronic acid on skeletal-related events. There is no validated method to determine which patients might benefit most from bisphosphonate therapy in this setting. Many questions about the use of bisphosphonate therapy in men with prostate cancer must be addressed, both in terms of the use in bone loss and bone metastases. These questions include: What is the optimal timing of therapy? Which bisphosphonate is best? What is the best dose and dose schedule? Do bisphosphonates effectively decrease skeletal fracture rates in patients with osteoporosis? How long should patients receive therapy? Are bisphosphonate "holidays" warranted? What are the long-term skeletal and renal toxicities? Is there a role for sequencing bisphosphonate therapy either before or after chemotherapy? Is bisphosphonate therapy synergistic with certain chemotherapy or other bone-targeted therapies? Which patients are the most likely to benefit from bisphosphonate therapy? What are clinically significant endpoints of bisphosphonate trials in patients with metastatic disease? Does inhibiting bone turnover also inhibit formation of bone metastases? Preliminary work in these areas has been completed, but more questions than answers are available. Given the rising costs of health care, it is imperative that these questions be addressed to best use the health care dollar while offering high-risk patients the best available therapy. At present, no data suggest that bisphosphonates should be used routinely to prevent BMD loss in men with normal BMD or to prevent the development of bone metastases in men with biochemical relapse. Continuing trials may give us guidance in the future.

Idiopathic or Hypogonadal Osteoporosis in Men

Osteoporosis is being recognized increasingly in men, and represents a substantial public health problem. As the male population ages and lives longer, the incidence of osteoporotic fractures is expected to increase. The current lifetime risk for a fragility fracture is approximately 27% in men aged 50 years or more, and will increase further over the next 20 years. A major problem with osteoporosis in men is that it continues to be unrecognized, and the majority of men with fragility fractures due to osteoporosis are not being treated. A higher level of awareness is required amongst both general practitioners and the general public that osteoporosis is a treatable condition that can affect men. Secondary causes for osteoporosis are more common in men than in women, and require rigorous exclusion and treatment. Undiagnosed clinical hypogonadism is a common cause of osteoporosis in men, and is readily treatable. The cause of primary osteoporosis in men is unknown, but it results in an osteoblast defect. Genetic factors are likely to be important. In some but not all men, relative estrogen deficiency contributes to rapid rates of age-related bone loss and fractures. An adequate calcium intake, regular weight-bearing exercise, and normal vitamin D status are all very important, particularly with increasing age. The role of testosterone in treating eugonadal men with osteoporosis is currently unclear, and larger prospective studies will be required to carefully evaluate the benefits and risks of therapy. First-line treatment of osteoporosis in hypogonadal or eugonadal men is with bisphosphonates. Alendronate increases bone density and reduces vertebral fractures measured using a semiquantitative method in eugonadal or hypogonadal men with osteoporosis. In the near future, it is likely that subcutaneous human parathyroid hormone (1-34) or teriparatide will also be available as an important new anabolic treatment for men with osteoporosis. Teriparatide treatment also increases bone density in men. Selective estrogen receptor modulating drugs require further evaluation in men, but would appear to theoretically benefit men, especially those with low estradiol levels. In the future, selective androgen receptor modulating drugs may be useful in the prevention and treatment of osteoporosis, and in increasing lean body mass in men, without having adverse effects on prostate and breast tissue.

Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women. A meta-analysis

BACKGROUND

In postmenopausal women, a history of any fracture is an important risk factor for a future hip fracture. Whether similar findings apply to aging men remains to be established. We conducted a systematic review and meta-analysis of the literature to compare men and women with respect to the relative risk of hip fracture after a wrist or spine fracture.

METHODS

Studies published in full from January 1982 through September 2002 in English, French, or German were identified from the PubMed database and from reference lists of retrieved articles. We included cohort studies that reported fractures associated with minimal trauma of the wrist or spine as a risk factor for a subsequent hip fracture among (white) women and men who were fifty years old or older. Data were extracted by two independent reviewers and were checked for accuracy in a second review. Differences in assessments were resolved by consensus of the two reviewers.

RESULTS

Nine cohort studies were included in this meta-analysis: five studies were conducted in the United States and four, in Europe. After homogeneity of association was demonstrated across all studies, a fixed-effects meta-analysis was used to calculate pooled relative risks with 95% confidence intervals. Among postmenopausal women, the relative risks for a future fracture of the hip after a fracture of the wrist or spine were 1.53 (95% confidence interval, 1.34 to 1.74; p < 0.001) and 2.20 (95% confidence interval, 1.92 to 2.51; p < 0.001), respectively. In older men, these relative risks were 3.26 (95% confidence interval, 2.08 to 5.11; p < 0.001) and 3.54 (95% confidence interval, 2.01 to 6.23; p < 0.001), respectively. Fractures of the distal part of the radius increased the relative risk of hip fracture significantly more in men than in women (p = 0.002). The impact of a spine fracture, conversely, did not differ between genders (p = 0.11). Sensitivity analyses with use of random-effects methodology confirmed these findings to be robust.

CONCLUSIONS

This meta-analysis suggests that a previous spine fracture has an equally important impact on the risk of a subsequent hip fracture in both genders. The prospective association between a Colles fracture and a subsequent hip fracture, however, is significantly stronger among men than among postmenopausal women. Men with a Colles fracture are at high risk for a future hip fracture and should be evaluated as candidates for preventive measures.

Male osteoporosis: epidemiology and pathophysiology

In men, osteoporosis is a prevalent problem that is under-recognized and undertreated. Men 50 years and older have a 13% lifetime risk for fracture. Hip and vertebral fractures are associated with significant functional impairment and increased mortality in men. The morbidity and mortality following a fracture is also greater in men than it is in women. By improving our knowledge on the pathophysiology of osteoporosis in men, better management strategies for this condition may be developed. In recent years, there has been greater awareness of the biomechanic factors that contribute to bone strength, which may explain some of the differences in fracture incidence between men and women. There is also growing evidence to support the key role of estrogens in maintaining bone health in older men, similar to women. This review highlights our current understandings on the epidemiology and pathophysiology of male osteoporosis and its related fractures, with particular focus on the determinants of bone strength and the role of sex hormones on bone metabolism in men.

Bioavailable estradiol and an aromatase gene polymorphism are determinants of bone mineral density changes in men over 70 years of age

The question of whether and to what extent the sex steroid deficiency in elderly men contributes to the pathogenesis of bone loss has not been fully explored. The aim of the present study was to assess the association of serum bioavailable (Bio) estradiol (E(2)) with the evolution of bone mineral density (BMD) in 214 community-dwelling men aged 71-86 yr as well as the possible modulation of estrogen effects by a tetranucleotide (TTTA)(n)-repeat polymorphism of the CYP19 gene, which encodes the aromatase enzyme that converts androgens into estrogens. BMD was measured at yearly intervals over a period of 4 yr using dual x-ray absorptiometry. Fasting blood was analyzed at baseline for testosterone (T), E(2), and SHBG; the respective bioavailable fractions, BioT and BioE(2), were calculated. Serum BioE(2) was associated with baseline BMD at different assessed skeletal sites, with correlation coefficients ranging between 0.23 and 0.37 (P < 0.001). Estimated annual percentage change of BMD (%BMD) was -0.39% [95% confidence index (CI), -0.56, -0.22] at the total hip, -0.04% (95% CI, -0.29, 0.21) at the femoral neck, and -0.37% (95% CI, -0.45, -0.29) at the total distal forearm. Higher circulating BioE(2) levels were associated with less bone loss at the forearm and the hip (P < 0.05). The CYP19 gene (TTTA)(n)-repeat length (determined by fragment analysis) was not associated with baseline BMD in the total group of elderly men. However, a significant association was observed between the CYP19 genotype and BMD change at the distal forearm; the highest bone loss was observed in subjects homozygotic for the shortest observed allele length of (TTTA)(7)-repeats (P < 0.02). The CYP19 (TTTA)(n)-repeat length was not associated with either baseline BioE(2) or the BioT/BioE(2) ratio. In multiple linear regression models, the CYP19 genotype and serum BioE(2) were determinants of %BMD change at the forearm (P < 0.05). No significant contribution of BioT to %BMD change was evident. As to fracture risk, the allele containing the shortest (TTTA)(n)-repeat length was more represented not only in elderly men with a positive personal fracture history (Pearson's chi(2) test = 4.03; df = 1; P = 0.05) but also in study subjects with a positive fracture history in their first-degree relatives (Pearson's chi(2) test = 6.48; df = 1; P = 0.01). In conclusion, the results of this prospective observational study support the view that BioE(2) is a determinant of bone density changes in elderly men and, furthermore, provide an indication that the aromatase enzyme may exert a direct modulatory action on bone metabolism at the tissue level in elderly men.

Pathophysiology of bone metastases from prostate cancer and the role of bisphosphonates in treatment

Metastasis to bone is a common feature in advanced prostate cancer patients. Current treatments, while effective in suppressing tumour growth and relieving tumour associated bone pain, do not provide long term remission or 'cure' for the disease. A greater understanding of prostate cancer metastasis is required if new treatment strategies are to be developed. Growth of tumour foci in skeletal sites is a major cause of morbidity in advanced prostate cancer and has required the development of specialised approaches to treatment, including the use of bisphosphonates. These drugs inhibit tumour induced osteoclastic bone resorption, thereby preventing skeletal related events and treatment induced bone loss. Zoledronic acid is currently the only bisphosphonate with proven benefit in prostate cancer. Bisphosphonates may also modify the bone microenvironment so that it becomes less favourable for the growth and survival of metastases. The most recent developments in our understanding of the advantages for growth and survival gained by metastatic prostate cancer cells in the skeleton are reviewed, along with the clinical evidence supporting the use of bisphosphonates in advanced prostate cancer.

Costs of prostate cancer, metastatic to the bone, in the Netherlands

OBJECTIVE

To quantify medical costs associated with bone metastases in patients with prostate cancer. Bone metastases in patients with prostate cancer are associated with considerable morbidity, negatively impact quality of life, and can add substantially to medical costs, given a median survival of 30-35 months from diagnosis of bone metastases.

METHODS

A retrospective cost analysis from both a community and university hospital in The Netherlands was conducted. Twenty-eight patient records (14 from each hospital) were investigated to assess the impact of skeletal-related events (SREs), including fractures, spinal cord compression, and radiotherapy, on total direct medical costs and cost of hospitalization. Costs are given in EUROS (Euros).

RESULTS

The average total cost of treatment was Euros 13,051 per patient over the 24-month follow-up period, which includes an average cost of Euros 6973 per patient to treat SREs. Treatment of SREs more than doubled total treatment costs. Patients in this analysis experienced, on average, one SRE per year, and the cost of SREs varied from Euros 1187 to Euros 40,948.

CONCLUSIONS

Occurrence of SREs contributes significantly to the cost of care for patients with advanced prostate cancer. These data suggest that bisphosphonates, which can reduce pain and SREs, may reduce healthcare costs.

Hip fractures among the elderly: causes, consequences and control

This review examines all pertinent literature sources published in the English language between 1966 to the present concerning hip fracture epidemiology, hip fracture injury mechanisms, and hip fracture management strategies. These data reveal hip fractures have several causes, but among these, the impact of falls and muscle weakness, along with low physical activity levels seems to be the most likely explanation for the rising incidence of hip fracture injuries. Related determinants of suboptimal nutrition, drugs that increase fall risk and lower the safety threshold and comorbid conditions of the neuromuscular system may also contribute to hip fracture disability. A number of interventions may help to prevent hip fracture injuries, including, interventions that optimize bone mass and quality, interventions that help prevent falls and falls dampening interventions. Rehabilitation outcomes may be improved by comprehensive interventions, prolonged follow-up strategies and ensuring that all aging adults enjoy optimal health.

Zoledronic Acid Significantly Reduces Pathologic Fractures in Patients with Advanced-Stage Prostate Cancer Metastatic to Bone

The skeletal complications of metastatic bone disease secondary to advanced prostate cancer result in significant morbidity. In particular, pathologic fractures often require clinical intervention and are independent predictors of mortality in men with advanced prostate cancer. Before the introduction of zoledronic acid, bisphosphonates had been shown to provide pain palliation in patients with prostate cancer and bone metastases but were not efficacious in preventing skeletal complications. Zoledronic acid is the first bisphosphonate to show efficacy in reducing skeletal complications associated with the predominantly osteoblastic bone lesions characteristic of prostate cancer. In a large phase III randomized trial, zoledronic acid 4 mg every 3 weeks for 15 months significantly reduced the percentage of men who experienced a skeletal complication and reduced the incidence of pathologic fractures. Additionally, zoledronic acid 4 mg significantly decreased the annual incidence of skeletal complications, including fractures, and provided better control of bone pain compared with placebo. Adverse events with zoledronic acid were primarily limited to the flu-like, acute-phase symptoms previously reported with intravenous bisphosphonates, namely fever, myalgia, nausea, and anemia. These adverse events were mild to moderate and easily managed with supportive care. Zoledronic acid is the first and only bisphosphonate shown to reduce skeletal morbidity, including fractures, in patients with advanced prostate cancer and bone metastases.

Broad clinical activity of zoledronic acid in osteolytic to osteoblastic bone lesions in patients with a broad range of solid tumors

Bone metastases are a common feature of a variety of solid tumors and are associated with substantial skeletal morbidity, including severe bone pain and pathologic fractures. Treatment with bisphosphonates, primarily pamidronate, is the current standard of care for patients with breast cancer and multiple myeloma who have predominantly osteolytic lesions. However, until recently no bisphosphonate had demonstrated efficacy in patients with osteoblastic lesions, which are common during the progression of prostate cancer and other solid tumors. Zoledronic acid, a potent, new-generation, nitrogen-containing bisphosphonate, has demonstrated significant benefits for patients with bone metastases resulting from a broad range of primary tumors, including multiple myeloma and breast, lung, kidney, and prostate cancers, and other solid tumors. Benefits include a decreased incidence of pathologic fractures and longer time to the first skeletal complication. Zoledronic acid is the first and only bisphosphonate to be proved effective in patients with all types of bone lesions, from osteolytic to osteoblastic, and therefore represents an important therapeutic advancement in the treatment of bone metastases.

Vitamin D receptor gene allelic variants, bone density, and bone turnover in community-dwelling men

The role of vitamin D receptor (VDR) gene polymorphisms in the determination of bone mass and bone turnover is controversial in women. The aim of the study was to determine whether VDR polymorphisms are associated with indices of bone mineral density (BMD) (by dual-energy X-ray absorptiometry and by ultrasound) and/or with bone turnover and muscle strength, factors related to both BMD and fracture risk. For this purpose, we investigated a cohort of community-dwelling men >70 years (n = 271) and a group of healthy control subjects between the ages of 20 and 50 years (n = 137). VDR TaqI, ApaI, and FokI genotypes were determined using enzymatic restriction digestion of polymerase chain reaction (PCR) fragments. In the elderly group, the lowest BMD value at the femoral neck and at the calcaneus was observed in subjects with the "At-At" haplotype genotype, with differences between extreme haplotype groups ("At-At" vs. noncarriers of the "At" allele) ranging from 5.8% to 34.3% (p < or = 0.05). Moreover, at the different subregions of the distal forearm and the tibia, the lowest BMD estimates were consistently associated in both elderly and younger men with the "At" haplotype allele, although this did not approach statistical significance. Elderly subjects with the "At-At" genotype had a significantly higher serum osteocalcin level. BMD was not significantly related to the FokI VDR polymorphism at any of the assessed skeletal sites, nor were any of the biochemical markers associated with the FokI VDR genotype. There were no differences between genotype groups for any of the indices of muscle strength. The present study indicates that the VDR genotype is associated with BMD in healthy community-dwelling elderly men and tends to be associated with biochemical markers, particularly of bone formation, in elderly men.