Incidence of hip fractures in the elderly: a cross-national analysis

Aging and Bone Metabolism

Changes in bone architecture and metabolism with aging increase the likelihood of osteoporosis and fracture. Age-onset osteoporosis is multifactorial, with contributory extrinsic and intrinsic factors including certain medical problems, specific prescription drugs, estrogen loss, secondary hyperparathyroidism, microenvironmental and cellular alterations in bone tissue, and mechanical unloading or immobilization. At the histological level, there are changes in trabecular and cortical bone as well as marrow cellularity, lineage switching of mesenchymal stem cells to an adipogenic fate, inadequate transduction of signals during skeletal loading, and predisposition toward senescent cell accumulation with production of a senescence-associated secretory phenotype. Cumulatively, these changes result in bone remodeling abnormalities that over time cause net bone loss typically seen in older adults. Age-related osteoporosis is a geriatric syndrome due to the multiple etiologies that converge upon the skeleton to produce the ultimate phenotypic changes that manifest as bone fragility. Bone tissue is dynamic but with tendencies toward poor osteoblastic bone formation and relative osteoclastic bone resorption with aging. Interactions with other aging physiologic systems, such as muscle, may also confer detrimental effects on the aging skeleton. Conversely, individuals who maintain their BMD experience a lower risk of fractures, disability, and mortality, suggesting that this phenotype may be a marker of successful aging. © 2023 American Physiological Society. Compr Physiol 13:4355-4386, 2023.

Sex Differences in the Burden of Hip Fractures on Functional Status in Older Age

Background: Hip fractures can dramatically impact the health and self-sufficiency of older people. We investigated the influence of pre-fracture functional status on functional decline and mortality after hip fracture, and possible sex differences in this regard. Materials and Methods: The sample comprised 288 older patients hospitalized with hip fracture in an Orthogeriatric Unit. Data on perioperative management and multidimensional evaluation were collected. After 15 months, we obtained information on housing arrangements, new falls, walking level, and self-sufficiency (Barthel Index [BI]) through outpatient visits or phone interviews. Data on re-hospitalizations and deaths were obtained from hospital records. Results: The sample median age was 87 years, and 75% were women. The median pre-fracture BI was 75 (interquartile range [IQR]: 50, 100), and at follow-up it decreased by a median of 20 (IQR: 40, -5) points. Sex differences emerged among those with the highest pre-fracture functional status (BI ≥85), with women showing lower BI loss than men (-15 [IQR: -40, 0] vs. -30 [IQR: -80, -15], respectively; p = 0.04). A pre-fracture BI ≥85 (vs. <85) was associated with a 41% lower mortality rate (95% confidence interval [95% CI]: 0.21-0.79), especially in women (hazard ratios = 0.28, 95% CI: 0.11-0.69). Moreover, male sex was an independent risk factor for functional loss after a hip fracture (odds ratio = 2.52, 95% CI: 1.09-5.80). Conclusions: Older men may have a worse functional prognosis than women after a hip fracture. This difference seemed to be exacerbated in cases of high pre-fracture functional performance, suggesting that females have a greater functional reserve, namely better adaptation and recovery strategies to deal with the fracture. Clinical Trial Registration: Registration code: NCT02687698.

Early functional outcome of hemiarthroplasty in the elderly with neck of femur fracture: A single centre’s experience

Introduction:

Neck of femur fractures in the elderly population are common and often a devastating condition. The optimal treatment has been a subject of debate. Arthroplasty has been shown to be the most viable treatment option. The high cost of total hip replacement makes hemiarthroplasty a suitable option in our environment.

Materials and Methods:

This study was designed to measure the outcome of hemiarthroplasty after femoral neck fracture using Harris hip score in patients aged 60 and above at the National Orthopaedic Hospital, Dala, Kano, Nigeria.

Results:

Twenty-five consecutive patients 60 years and above with femoral neck fracture who met the inclusion criteria and gave consent were enrolled into the study. The mean Harris hip score at the pre-operative period was 16.92. Fourth week after the surgery, the mean Harris hip score was 69.96. The score rose further to 75.24 and 80.96 at 12 weeks and 6 months post-operatively. The difference between the mean pre-operative and post-operative scores at 4th week, 12th week, and 6th month was statistically significant. During the pre-operative period, all patients had a poor Harris hip score grade. Six months after the surgery, 7 patients (28%) had an excellent Harris hip score grade, 12 patients (48%) had good grades, and 1 patient (4%) had a fair Harris hip score grade. Five patients (20%) had a poor Harris hip score grade at 6 months.

Conclusion:

From the findings of this study, it can be concluded that early functional outcomes of hemiarthroplasty for femoral neck fracture in the elderly are good and satisfactory.

The Global Burden of Osteoporosis, Low Bone Mass, and Its Related Fracture in 204 Countries and Territories, 1990-2019

BACKGROUND

Low bone mineral density (LBMD), including osteoporosis and low bone mass, has becoming a serious public health concern. We aimed to estimate the disease burden of LBMD and its related fractures in 204 countries and territories over the past 30 years.

METHODS

We collected detailed information and performed a secondary analysis for LBMD and its related fractures from the Global Burden of Disease Study 2019. Numbers and age-standardized rates related to LBMD of disability-adjusted life-years (DALYs) and deaths in 204 countries and territories were compared by age, gender, socio-demographic index (SDI), and location.

RESULTS

Global deaths and DALYs number attributable to LBMD increased from 207 367 and 8 588 936 in 1990 to 437 884 and 16 647 466 in 2019, with a raise of 111.16% and 93.82%, respectively. DALYs and deaths number of LBMD-related fractures increased 121.07% and 148.65% from 4 436 789 and 121248 in 1990 to 9 808 464 and 301 482 in 2019. In 2019, the five countries with the highest disease burden of DALYs number in LBMD-related fractures were India (2 510 288), China (1 839 375), United States of America (819 445), Japan (323 094), and Germany (297 944), accounting for 25.59%, 18.75%, 8.35%, 3.29%, and 3.04%. There was a quadratic correlation between socio-demographic index (SDI) and burden of LBMD-related fractures: DALYs rate was 179.985-420.435SDI+417.936SDI²(R^{2 =} 0.188, p<0.001); Deaths rate was 7.879-13.416SDI+8.839 SDI²(R^{2 =} 0.101, p<0.001).

CONCLUSIONS

The global burden of DALYs and deaths associated with LBMD and its related fractures has increased significantly since 1990. There were differences in disease burden between regions and countries. These estimations could be useful in priority setting, policy-making, and resource allocation in osteoporosis prevention and treatment.

Fall Patterns Predict Mortality After Hip Fracture in Older Adults, Independent of Age, Sex, and Comorbidities

Falls are the most frequent cause of hip fracture. We aimed to investigate whether specific fall patterns have predictive value for mortality after hip fracture. In this cohort study, data of individuals presented to the Severance Hospital, Seoul, Korea, between 2005 and 2019 due to fragility hip fracture (n = 1986) were analyzed. Fall patterns were defined as causes, activities leading to falls, and a combination of both, based on electronic medical records using pre-specified classification from a prior study on video-captured falls. Mean age of study subjects were 77 years (71% women) and 211 patients (10.6%) died during follow-up (median 544 days). Indoor falls at home had a higher mortality than outdoor falls (11.9 vs. 8.0%, p = 0.009). Among 16 fall patterns, incorrect weight shift while sitting down (adjusted hazard ratio [aHR] 4.03) or getting up (aHR 2.01), collapse during low-risk activity (aHR 2.39), and slipping while walking (aHR 2.90, p < 0.01 for all) were associated with increased mortality compared to outdoor falls, after adjustment for age, sex, and Charlson comorbidity index (CCI), constituting a high-risk pattern. High-risk fall patterns were associated with a higher risk of mortality (aHR 2.56, p < 0.001) than low-risk patterns (aHR 1.37, p = 0.080) and outdoor falls (referent; log rank p < 0.001), which improved mortality prediction when added to a base model including age, sex, and CCI (integrative area under receiver-operating characteristics curve 0.675 to 0.698, p < 0.001). Specific fall patterns were associated with higher mortality in older adults with hip fracture, independent of age, sex, and comorbidities.

Osteosarcopenia: where osteoporosis and sarcopenia collide

The coexistence of osteoporosis and sarcopenia has been recently considered in some groups as a syndrome termed 'osteosarcopenia'. Osteoporosis describes low bone mass and deterioration of the micro-architecture of the bone, whereas sarcopenia is the loss of muscle mass, strength and function. With an ageing population the prevalence of both conditions is likely to increase substantially over the coming decades and is associated with significant personal and societal burden. The sequelae for an individual suffering from both conditions together include a greater risk of falls, fractures, institutionalization and mortality. The aetiology of 'osteosarcopenia' is multifactorial with several factors linking muscle and bone function, including genetics, age, inflammation and obesity. Several biochemical pathways have been identified that are facilitating the development of several promising therapeutic agents, which target both muscle and bone. In the current review we outline the epidemiology, pathogenesis and clinical consequences of 'osteosarcopenia' and explore current and potential future management strategies.

ASA Physical Status Classification Improves Predictive Ability of a Validated Trauma Risk Score

Introduction:

The Score for Trauma Triage in the Geriatric and Middle-Aged (STTGMA) is a validated mortality risk score that evaluates 4 major physiologic criteria: age, comorbidities, vital signs, and anatomic injuries. The aim of this study was to investigate whether the addition of ASA physical status classification system to the STTGMA tool would improve risk stratification of a middle-aged and elderly trauma population.

Methods:

A total of 1332 patients aged 55 years and older who sustained a hip fracture through a low-energy mechanism between October 2014 and February 2020 were included. The STTGMA and STTGMAASA mortality risk scores were calculated. The ability of the models to predict inpatient mortality was compared using area under the receiver operating characteristic curves (AUROCs) by DeLong’s test. Patients were stratified into minimal, low, moderate, and high risk cohorts based on their risk scores. Comparative analyses between risk score stratification distribution of mortality, complications, length of stay, ICU admission, and readmission were performed using Fisher’s exact test. Total cost of admission was fitted by univariate linear regression with STTGMA and STTGMAASA.

Results:

There were 27 inpatient mortalities (2.0%). When STTGMA was used, the AUROC was 0.742. When STTGMAASA was used, the AUROC was 0.823. DeLong’s test resulted in significant difference in predictive capacity for inpatient mortality between STTGMA and STTGMAASA (p = 0.04). Risk score stratification yielded significantly different distribution of all outcomes between risk cohorts (p < 0.01). STTGMAASA stratification produced a larger percentage of all negative outcomes with increasing risk cohort. Total hospital cost was statistically correlated with both STTGMAASA (p < 0.01) and STTGMA (p = 0.02).

Conclusion:

Including ASA physical status as a variable in STTGMA improves the model’s ability to predict inpatient mortality and risk stratify middle-aged and geriatric hip fracture patients.

Evolutionary Perspectives on the Developing Skeleton and Implications for Lifelong Health

Osteoporosis is a significant cause of morbidity and mortality in contemporary populations. This common disease of aging results from a state of bone fragility that occurs with low bone mass and loss of bone quality. Osteoporosis is thought to have origins in childhood. During growth and development, there are rapid gains in bone dimensions, mass, and strength. Peak bone mass is attained in young adulthood, well after the cessation of linear growth, and is a major determinant of osteoporosis later in life. Here we discuss the evolutionary implications of osteoporosis as a disease with developmental origins that is shaped by the interaction among genes, behavior, health status, and the environment during the attainment of peak bone mass. Studies of contemporary populations show that growth, body composition, sexual maturation, physical activity, nutritional status, and dietary intake are determinants of childhood bone accretion, and provide context for interpreting bone strength and osteoporosis in skeletal populations. Studies of skeletal populations demonstrate the role of subsistence strategies, social context, and occupation in the development of skeletal strength. Comparisons of contemporary living populations and archeological skeletal populations suggest declines in bone density and strength that have been occurring since the Pleistocene. Aspects of western lifestyles carry implications for optimal peak bone mass attainment and lifelong skeletal health, from increased longevity to circumstances during development such as obesity and sedentism. In light of these considerations, osteoporosis is a disease of contemporary human evolution and evolutionary perspectives provide a key lens for interpreting the changing global patterns of osteoporosis in human health.

Epidemiology and social costs of hip fracture

Hip fracture is an important and debilitating condition in older people, particularly in women. The epidemiological data varies between countries, but it is globally estimated that hip fractures will affect around 18% of women and 6% of men. Although the age-standardised incidence is gradually falling in many countries, this is far outweighed by the ageing of the population. Thus, the global number of hip fractures is expected to increase from 1.26 million in 1990 to 4.5 million by the year 2050. The direct costs associated with this condition are enormous since it requires a long period of hospitalisation and subsequent rehabilitation. Furthermore, hip fracture is associated with the development of other negative consequences, such as disability, depression, and cardiovascular diseases, with additional costs for society. In this review, we show the most recent epidemiological data regarding hip fracture, indicating the well-known risk factors and conditions that seem relevant for determining this condition. A specific part is dedicated to the social costs due to hip fracture. Although the costs of hip fracture are probably comparable to other common diseases with a high hospitalisation rate (e.g. cardiovascular disease), the other social costs (due to onset of new co-morbidities, sarcopenia, poor quality of life, disability and mortality) are probably greater.

Incidental hip fracture in an outpatient clinic: the importance of patient-centred assessment

ABSTRACT Although many patients presenting with hip fractures have classic symptoms, other patients may present atypically with referred knee pain and reasonably unremarkable clinical examination following initial presentation. Older patients commonly have comorbid conditions such as arthritis, stroke and dementia that can complicate history and examination, making the diagnosis of subtle fractures difficult. Multimorbidity represents an important diagnostic challenge to both primary and secondary care. This case study discusses a 90-year-old lady who was found to have an old right neck of femur fracture after attendance at an geriatric outpatient clinic for a discussion about anticoagulation, after GP referral.

Proximal femoral fractures in elderly people: time to surgery. The experience of Milan's "ASST Pini/CTO"

Proximal femoral fractures in elderly patients represent a rapidly increasing socio-economic problem. The functional recovery and the mortality rate are influenced by a substantial quantity of variables, including the waiting time for surgical treatment ("time to surgery"). This study aims at investigating the average waiting time, and ascertaining the causes and effects, together with other non-modifiable variables, on the outcome for patients admitted to Milan's Istituto Ortopedico Gaetano Pini (Gaetano Pini Orthopaedic Institute) with a proximal femoral fracture. Data have been collected from 234 patients, between May and November 2015. Parameters recorded and analysed included fracture type, presence of comorbidities (Charlson Index (CCI)), the ASA (American Society of Anesthesiology) score, day of the week presenting to hospital, the type of treatment received, the functional recovery, and the patient's condition on discharge. In 46.4% of cases, the duration of preoperative stay prior to surgery was found to be in line with what is recommended in the literature (<48 h). In 20% of cases, the time to surgery was found to exceed 96 hours. The data collected that pertain to the distribution of the sample and the comorbidities were shown to be in line with the literature. A statistical significant difference was found between day of the week that the patient was admitted to hospital and the waiting time for surgery.

Redox Status in Patients with Femoral Neck Fractures

The femur transfers the body weight from the pelvic bone to the shinbone. Femur fractures are a significant cause of morbidity and mortality among the group of locomotor apparatus injuries, especially in the elderly population. Considering that oxidative stress occurs as a result of increased production of free radicals that damage cell function and cause numerous pathological conditions and diseases, the aim of this study was to investigate oxidative stress parameters in older patients with femoral neck fractures. This clinical study included 70 patients, of which 35 had femoral neck fractures (26 males and 9 females), while the other half of the patients formed the matched control group. Markers of oxidative stress (NO2 −, TBARS, H2O2 and O2 -) and anti-oxidative enzymes (SOD, CAT, and GSH) were measured. Results showed that the levels of O2 - increased, while levels of NO2 -, H2O2 and all the antioxidative enzymes decreased in patients with femoral neck fractures. These findings indicate that fractures cause oxidative stress, probably because of the reduced activity of osteoblasts and the increased activity of osteoclasts.

Incidence and excess mortality of hip fracture in young adults: a nationwide population-based cohort study

Background

This study assessed the incidence and excess mortality of hip fractures among inpatients aged 20–40 years in a nationwide population database in Taiwan.

Methods

Subjects were selected from Taiwan’s National Health Insurance Research Database for the period 2001–2008 and were followed up until the end of 2010. A total of 4,523 subjects were admitted for the first time with primary diagnosis of hip fracture and treated with operation.

Results

The overall annual incidence, mortality, and standardized mortality ratio (SMR) decreased from 7.68 to 7.23 per 100,000, from 1.37 % to 0.94 %, and from 9.06 to 6.71, respectively, from 2001 to 2008. The 1-year, 2-year, 3-year, 5-year, and 10-year mortality rates were 1.28 %, 2.44 %, 3.54 %, 5.32 %, and 10.50 %, respectively for the whole cohort. The 1-year, 2-year, 3-year, 5-year, and 10-year SMRs were 8.33, 7.59, 7.28, 6.39, and 5.82, respectively, for the whole cohort. Risk factors for overall death were male gender, trochanteric fracture, hemiarthroplasty, and higher Charlson comorbidity index (CCI) scores.

Conclusions

The high SMRs found in the present study suggest that young adults with former hip fracture should be closely followed up to prevent early mortality.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-016-1166-9) contains supplementary material, which is available to authorized users.

No increase in risk of hip fracture at high serum retinol concentrations in community-dwelling older Norwegians: the Norwegian Epidemiologic Osteoporosis Studies

BACKGROUND

Norway has the highest hip fracture rates worldwide and a relatively high vitamin A intake. Increased fracture risk at high intakes and serum concentrations of retinol (s-retinol) have been observed in epidemiologic studies.

OBJECTIVE

We aimed to study the association between s-retinol and hip fracture and whether high s-retinol may counteract a preventive effect of vitamin D.

DESIGN

We conducted the largest prospective analysis of serum retinol and hip fracture to date in 21,774 men and women aged 65-79 y (mean age: 72 y) who attended 4 community-based health studies during 1994-2001. Incident hip fractures occurring up to 10.7 y after baseline were retrieved from electronic hospital discharge registers. Retinol determined by high-pressure liquid chromatography with ultraviolet detection in stored serum was available in 1154 incident hip fracture cases with valid body mass index (BMI) data and in a subcohort defined as a sex-stratified random sample (n = 1418). Cox proportional hazards regression weighted according to the stratified case-cohort design was performed.

RESULTS

There was a modest increased risk of hip fracture in the lowest compared with the middle quintile of s-retinol (HR: 1.41; 95% CI: 1.09, 1.82) adjusted for sex and study center. The association was attenuated after adjustment for BMI and serum concentrations of α-tocopherol (HR: 1.16; 95% CI: 0.88, 1.51). We found no increased risk in the upper compared with the middle quintile. No significant interaction between serum concentrations of 25-hydroxyvitamin D and s-retinol on hip fracture was observed (P = 0.68).

CONCLUSIONS

We found no evidence of an adverse effect of high serum retinol on hip fracture or any interaction between retinol and 25-hydroxyvitamin D. If anything, there tended to be an increased risk at low retinol concentrations, which was attenuated after control for confounders. We propose that cod liver oil, a commonly used food supplement in Norway, should not be discouraged as a natural source of vitamin D for fracture prevention.

Determinants of Muscle and Bone Aging

Loss of bone and muscle with advancing age represent a huge threat to loss of independence in later life. Osteoporosis represents a major public health problem through its association with fragility fractures, primarily of the hip, spine and distal forearm. Sarcopenia, the age related loss of muscle mass and function, may add to fracture risk by increasing falls risk. In the context of muscle aging, it is important to remember that it is not just a decline in muscle mass which contributes to the deterioration of muscle function. Other factors underpinning muscle quality come into play, including muscle composition, aerobic capacity and metabolism, fatty infiltration, insulin resistance, fibrosis and neural activation. Genetic, developmental, endocrine and lifestyle factors, such as physical activity, smoking and poor diet have dual effects on both muscle and bone mass in later life and these will be reviewed here. Recent work has highlighted a possible role for the early environment. Inflammaging is an exciting emerging research field that is likely to prove relevant to future work, including interventions designed to retard to reverse bone and muscle loss with age.

Racial/ethnic and socioeconomic differences in bone loss among men

As men age, they lose bone and are susceptible to fracture. Despite having lower fracture rates than women, men have worse fractures than women do. Racial/ethnic and socioeconomic status (SES) disparities in fracture rates exist, yet data on rates of bone loss by race/ethnicity and SES among men are limited. We examined annualized percentage change in bone mineral density (%ΔBMD) at the hip (N = 681), spine (N = 663), and forearm (N = 636) during 7 years of follow-up among men aged 30-79 years at baseline. Multivariable models tested whether race/ethnicity, income, or genetic ancestry predicted annualized %ΔBMD after controlling for an extensive set of covariates. Annualized %ΔBMD ranged from -0.65(0.04)% (femoral neck) to +0.26(0.03)% (1/3 distal radius), and changes were consistent across age groups with the exception of the ultradistal radius, where annualized declines increased with age. Neither self-identified race/ethnicity nor genetic ancestry were associated with annualized %ΔBMD. In contrast, income was strongly associated (dose-response) with annualized %ΔBMD at total hip (independent of confounders, self-identified race/ethnicity, and genetic ancestry). Fully adjusted least-square mean change in annualized %ΔBMD at the total hip were -0.24(0.12)% and -0.16(0.06)% steeper among men with low and moderate incomes, respectively, than among men with higher incomes (overall p = 0.0293). Results show a linear decline in bone that begins relatively early in life among men, that rates of bone loss do not vary with race/ethnicity (self-identified or "objectively" measured), and that income plays an important role in relation to bone loss at the hip. These data suggest that fracture risk in men may be driven in part by income-related differences in bone loss, but also, that the known higher fracture risk among white men is not the result of racial/ethnic differences in bone loss, but rather, early life exposures that lead to attainment of higher peak bone mass among minorities.

Femoral head diameter in the Malaysian population

INTRODUCTION

Hip arthroplasty is commonly performed worldwide. The objective of this study was to determine the diameter of the femoral head in the Malaysian population in relation to gender and race (i.e. among Malay, Chinese and Indian patients).

METHODS

This was a retrospective cross-sectional study performed between January 1995 and December 2006, evaluating the femoral head diameters of all patients aged 50 years and above who underwent hemiarthroplasty at two major hospitals in Malaysia.

RESULTS

A total of 945 femoral heads (663 women, 282 men) were evaluated. The mean age of the patients in our cohort was 75.2 ± 9.4 (range 50-101) years. The mean femoral head diameter (with intact articular cartilage) was 44.9 ± 3.2 (range 38-54) mm. In our study, men had a significantly larger mean femoral head diameter than women (47.7 ± 2.8 mm vs. 43.7 ± 2.4 mm; p < 0.05). Patients of Chinese ethnicity were also found to have significantly larger femoral head diameters, when compared among the three races studied (p < 0.05).

CONCLUSION

Malaysians have a mean femoral head diameter of 44.9 ± 3.2 mm. Among our patients, Chinese patients had a significantly larger femoral head size than Malay and Indian patients. We also found that, in our cohort, men had significantly larger femoral head diameters than women.

Osteoporosis in men

OBJECTIVE

To review information pertinent to bone health and osteoporosis in men.

METHODS

A review of pertinent literature was conducted.

RESULTS

Osteoporosis affects approximately 2 million men in the US and accounts for an estimated 600,000 fractures each year. There are significant differences in skeletal size and structure between men and women that account for differences in fracture incidence, location, and outcomes. Bone density testing is appropriate for men age 70 and older and younger men (50-69) who have risk factors for osteoporosis. Lifestyle management, including adequate calcium and vitamin D intake, appropriate physical activity, and avoidance of tobacco and heavy alcohol use, is appropriate for all men. Pharmacologic therapy to reduce fracture risk is advisable for men with a clinical diagnosis of osteoporosis (a spine or hip fracture) or a T-score of -2.5 or below in the spine, femoral neck, total hip or 1/3 radius; however, the majority of men at high risk will only be identified using a fracture risk assessment tool, such as FRAX. Alendronate, risedronate, zoledronic acid, denosumab, and teriparatide are Food and Drug Administration (FDA)-approved therapeutic options.

CONCLUSIONS

Osteoporosis in men presents an important public health problem with significant morbidity and mortality. There are recommended strategies for identifying men at high risk of fracture, and effective agents are available for treatment.

Factors in relation to bone mineral density in Korean middle-aged and older men: 2008-2010 Korea National Health and Nutrition Examination Survey

BACKGROUND/AIMS

Studies on determinants of bone mineral density (BMD) among Asian middle-aged and older men are very limited. The aim of this study was to investigate general determinants and dietary factors influencing BMD in Korean middle-aged and older men.

METHODS

This study was conducted using data from the 2008-2010 Korea National Health and Nutrition Examination Survey. A total of 2,305 male subjects aged 50-79 years were included. Whole-body, total femur, femoral neck, and lumbar spine BMDs were measured by dual-energy X-ray absorptiometry. Dietary intake was estimated by 24-hour dietary recall. A food frequency questionnaire for 63 food items was also administered.

RESULTS

Proportions of osteoporosis at the total femur, femoral neck, and lumbar spine were 0.7, 3.3 and 7.0%, respectively. Age, height, weight, body mass index, fat mass, lean body mass, waist circumference, serum vitamin D, parathyroid hormone, and exercise were related to BMD, but the relationships were site specific. Diet quality and intake of vegetables, fruits, and calcium were associated with BMD.

CONCLUSIONS

These results suggest that a high-quality diet, an adequate intake of fruits, vegetables, and calcium, as well as exercise, high serum vitamin D and weight maintenance might be determinants of BMD among middle-aged and older Asian men.

Mechanisms of hip fracture in owerri, Nigeria, and its associated variables

Background:

Hip fracture has been associated with various risk factors, including osteoporosis, excessive alcohol consumption, physical inactivity, visual impairment, aging, sex, rural/urban inhabitation, race and climatic variations. Mechanisms of hip fractures in many parts of the world have been documented, and include road traffic accident (RTA), gunshot injury, fall from heights and many others. There is paucity of such documentation in Owerri, Nigeria.

Aim:

This study was designed to investigate the mechanism of hip fractures in Owerri, Nigeria, and to determine its prevailing factors.

Materials and Methods:

The study was conducted in hospitals located in Owerri, Nigeria. Cases of hip fracture were identified from the medical register while data were sourced from the medical record department for hip fractures that occurred between 1^st January 2002 and 31^st December 2008 for patients resident in Owerri and aged between 10 years and above.

Results:

The study uncovered a total of 105 cases of hip fractures over the study period in 65% (n = 68) males and 35% (n = 37) females. Proportion of hip fractures as a result of fragility fracture mechanisms was significantly higher in females than in the males (P < 0.001), while the reverse was the case for RTA mechanisms. In the same vein, proportion of hip fractures as a result of moderate trauma mechanisms was significantly higher in the elderly than in the young patients (P < 0.001), while the reverse was the case for RTA mechanisms.

Conclusion:

Mechanism of hip fractures in Owerri, Nigeria, can be associated with gender and age. RTA had the largest single contributory mechanism of hip fractures in Owerri. Therefore, public health campaigns and promotions should be created to reduce the influence of RTA on hip fracture among this population. Among the elderly population, hip fracture was mostly sustained from fragility trauma mechanisms, suggesting that osteoporosis is a major contributory factor of hip fracture among this population.

Increasing incidence of hip fracture in Chiang Mai, Thailand

Hip fracture is a major health problem in Thailand. This study attempted to examine the incidence, related factors, and trends of hip fracture in Chiang Mai, Thailand. All hip fracture data among patients aged 50 yr or older were collected from hospitals in Chiang Mai, Thailand from August 1, 2006 to July 3, 2007. Data from the 1997 Chiang Mai hip fracture study were used for comparison. In the study period, 690 hip fractures were reported: 203 males and 487 females (male to female ratio was 1 to 2.4), with a mean age of 76.7 yr. The estimated cumulative incidence was 181.0 per 100,000, and the adjusted incidence was 253.3 (males: 135.9; females: 367.9). A simple fall was the most common mechanism (79%) of fracture, and 80% of the hip fractures occurred in patients aged 70 yr or older. The highest incidence of hip fracture was observed in patients older than 85 yr (1239). At 6 mo postfracture, most patients (61%) used a walking aid. Compared with the 1997 data, hip fracture incidence had increased by an average of 2% per yr, and the incidence of hip fracture had increased significantly from August 1, 2006 to July 31, 2007, especially in patients older than 75 yr. In patients older than 84 yr, the incidence increased by a factor of 2. Urgent strategies for the prevention and treatment of osteoporosis, and hence hip fracture, are needed.

Discrepancy in bone mineral densities at different skeletal sites in hip osteoarthritis patients

OBJECTIVE: Increased femoral neck bone mineral density (BMD) in a hip with osteoarthritis (OA) has been previously reported, however, it is possible that increased BMD at sites other than the hip joint is influenced by the disease process of OA. Therefore, we measured BMD at locations different from the hip joint and determined whether higher BMD was also observed at these different skeletal sites in hip OA patients. METHODS: We measured BMD in 68 women (average age 61.0 years) scheduled to undergo total hip arthroplasty for end-stage OA and 100 healthy women (average age 60.9 years) as age-matched controls. BMD at the lumbar spine, radius, and calcaneus was measured by dual-energy X-ray absorptiometry (DXA). Moreover, we measured speed of sound (SOS), broadband ultrasound attenuation (BUA), and stiffness index of the calcaneus by quantitative ultrasonography (QUS). RESULTS: BMD obtained by DXA at the lumbar spine and radius was significantly higher in hip OA patients than in controls. However, at the calcaneus, no significant differences were observed between the groups in BMD obtained by DXA. SOS, BUA, and stiffness index obtained by QUS were significantly lower in the OA group than in controls. CONCLUSION: Higher BMDs of the spine and radius suggest that the incidence of osteoporosis is inversely associated with the incidence of OA. However, it remains unclear whether lack of difference in BMD and lower SOS, BUA, and stiffness index of the calcaneus in the OA group was secondary to the effect walking disturbance resulting from hip pain. Our data suggest that hip OA patients have higher BMD than healthy women, and that inactivity or immobilization caused by hip OA may reduce BMD in the lower limb.

Osteoporosis in men: an Endocrine Society clinical practice guideline

OBJECTIVE

The aim was to formulate practice guidelines for management of osteoporosis in men.

EVIDENCE

We used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and evidence quality.

CONSENSUS PROCESS

Consensus was guided by systematic evidence reviews, one in-person meeting, and multiple conference calls and e-mails. Task Force drafts were reviewed successively by The Endocrine Society's Clinical Guidelines Subcommittee and Clinical Affairs Core Committee; representatives of ASBMR, ECTS, ESE, ISCD; and members at large. At each stage, the Task Force received written comments and incorporated needed changes. The reviewed document was approved by The Endocrine Society Council before submission for peer review.

CONCLUSIONS

Osteoporosis in men causes significant morbidity and mortality. We recommend testing higher risk men [aged ≥70 and men aged 50-69 who have risk factors (e.g. low body weight, prior fracture as an adult, smoking, etc.)] using central dual-energy x-ray absorptiometry. Laboratory testing should be done to detect contributing causes. Adequate calcium and vitamin D and weight-bearing exercise should be encouraged; smoking and excessive alcohol should be avoided. Pharmacological treatment is recommended for men aged 50 or older who have had spine or hip fractures, those with T-scores of -2.5 or below, and men at high risk of fracture based on low bone mineral density and/or clinical risk factors. Treatment should be monitored with serial dual-energy x-ray absorptiometry testing.

Hip arthroplasty after intramedullary hip screw fixation: a perioperative evaluation

OBJECTIVES

Although literature exists regarding surgery after hip screw/side plate devices, we are unaware of any reports of hip arthroplasty after intramedullary devices.

DESIGN

This is a retrospectively reviewed case series.

SETTING

Tertiary care medical center.

PATIENTS/PARTICIPANTS

A consecutive unselected series.

INTERVENTION

Hip arthroplasty surgery after failed hip fracture fixation surgery using an intramedullary nail device.

MAIN OUTCOME MEASUREMENTS

Twenty cases of conversion surgery after intramedullary fixation for hip fractures were retrospectively reviewed.

RESULTS

The indications for hip arthroplasty were nonunion with failed fixation in 15, avascular necrosis with secondary hip arthritis in three, and progression of hip arthritis in four. Average operative time and blood loss were 166 minutes and 621 mL, respectively. Of note, nine of 20 patients ultimately developed a nonunion of the greater trochanter after hip arthroplasty. In only one of these cases of nonunion was the greater trochanter refractured intraoperatively and this as part of a trochanteric osteotomy.

CONCLUSION

Patients undergoing hip arthroplasty after failed hip fracture fixation using an intramedullary nail device are at high risk for greater trochanteric fracture and nonunion. The average operative time and blood loss for these procedures were greater than reported for primary but less than for revision arthroplasty. We now consider treating these cases with a trochanteric plate with or without a trochanteric slide osteotomy to minimize fracture of the remaining, damaged trochanteric bone.

LEVEL OF EVIDENCE

Therapeutic Level IV. See page 128 for a complete description of levels of evidence.

Studies on health in elderly observation centers (abbreviated from Italian: COSA): a multidimensional evaluation (MDE) of an elderly population frequenting a diurnal center in Catania

The worldwide progressive aging of the population forces us to reconsider the strategies of evaluation the effects of the geriatric "tsunami" on the health politics. The present study on the COSA (abbreviated from the Italian name: "Centro Osservazione Salute Anziani") has the aim to investigate the effects of a new form called Specialistic Geriatric Assistance on the already existing geriatric services in our territory, like UVG (Unità Valutazione Geriatrica), ADI (Assistenza Domiciliare Integrata), MMG (Medici di Medicina Generale). The present preliminary studies were carried out a group of elderly people frequenting the elderly day center "Villa Angela" located in Catania. We enrolled 42 subjects, 29 females and 13 males, in the age-range of 65-89 years (mean=73.6 years). An evaluation protocol was used for the participants, having two parts. The first part was a general one performing an accurate anamnestic examination, while the second part evaluated the cognitive and affective spheres, and the levels of autonomy and autosufficiency. The data obtained show that that the elderly population of the daily center "Villa Angela" in Catania is affected by numerous pathologies and comorbidities, which all increase the total risk of disabilities. The subjects use a high number of medicines (sometimes more than 10), which is not always justified by the pathologies found in them. Considering the functional profiles of the patients, the sanitary services offered to them are appropriate, because almost all of the elderly people were autonomous and autosufficient, having still adequate physical performances. The higher cognitive performance seemed to be reduced in more than 50% of the patients, showing almost always a slight or moderate deterioration. The depressive state measured by the GDS seemed to reach the deflection of joy of life 54.8%, while the established depression was detected in 12%. These results emphasize the importance of the functional psychogeriatric screening, which is able to reveal an early diagnosis of depression in the geriatric ages. For this, and many other motifs, we believe that these preliminary examinations suggest to organize at least one COSA available to our elderly people.

Geographic trends in incidence of hip fractures: a comprehensive literature review

A comprehensive review of literature was conducted to investigate variation in hip fracture incident rates around the world. The original crude incidence rates were standardized for age and sex for comparability. After standardization, the highest rates of hip fracture were found in Scandinavia and the lowest rates in Africa.

INTRODUCTION

This study was conducted to investigate the geographic trends of the incidence of osteoporotic hip fractures through a comprehensive review of literature.

METHODS

Studies were identified for inclusion in the review by searching the MEDLINE database via PubMed and applying strict inclusion and exclusion criteria. Age-specific incidence rates were extracted from the articles, and in order to provide a common platform for analysis, we used directly age-standardized and age-sex-standardized rates (using the 2005 United Nations estimates of the world population as standard) to complete the analysis.

RESULTS

Forty-six full text articles spanning 33 countries/regions were included in the review. For ease of comparison, the results were analyzed by geographic regions: North America, Latin America, Scandinavia, Europe (excluding Scandinavia), Africa, Asia, and Australia. The highest hip fracture rates were found in Scandinavia and the lowest in Africa. We found comparable rates from countries in North America, Australia, and Europe outside of Scandinavia. The diverse makeup of the Asian continent also resulted in quite variable hip fracture rates: ranging from relatively high rates in Iran to low rates, comparable to those from Africa, in mainland China.

CONCLUSIONS

Given the aging of populations globally, and in the industrialized countries specifically, hip fractures will become a progressively larger public health burden. The geographic trends observed in hip fracture incidence rates can provide important clues to etiology and prevention.

Gender differences in osteoporosis and fractures

BACKGROUND

Osteoporosis is generally thought of as a "woman's disease" because the prevalence of osteoporosis and the rate of fractures are much higher in postmenopausal women than in older men. However, the absolute number of men affected by osteoporosis and fractures is large, as at least 2.8 million men in the United States are thought to have osteoporosis.

QUESTIONS/PURPOSES

The purposes of this review are to (1) highlight gender differences in osteoporosis and fracture risk, (2) describe disparities in treatment and outcomes after fractures between men and women, and (3) propose solutions to reducing disparities in treatment and prevention.

METHODS

A literature survey was conducted using MEDLINE with a variety of search terms and using references from the author's personal collection of articles. A formal search strategy and exclusion criteria were not employed and the review is therefore selective. WHERE ARE WE NOW?: Postmenopausal women have a higher prevalence of osteoporosis and greater incidence of fracture than older men. Despite the higher fracture risk in postmenopausal women, older men tend to have worse outcomes after fracture and poorer treatment rates, although less is known about the disease course in men. Multifaceted interventions to improve the screening and treatment for osteoporosis were recently developed. WHERE DO WE NEED TO GO?: Improvement in treatment rates of those at risk, regardless of gender, is an important goal in osteoporosis management. HOW DO WE GET THERE?: Further development and evaluation of cost-effective, multifaceted interventions for screening and treatment of osteoporosis and fractures are needed; such interventions will likely improve the primary prevention of fractures.

Effect of tetracalcium dimagnesium phytate on bone characteristics in ovariectomized rats

The aim was to evaluate the influence of dietary Ca-Mg-phytate consumption on the bone characteristics of ovariectomized rats, an animal model for postmenopausal osteoporosis. Twenty ovariectomized female Wistar rats were randomly assigned to two groups fed, respectively, with a non-phytate diet (AIN-76A) or the same diet enriched with 1% phytate (as the calcium magnesium salt, phytin). After 12 weeks of feeding the rats were sacrificed, and both femoral bones and L4 vertebra were removed from each rat. Bone mass, length, width, volume, and mineral density were measured, and the phosphorus, calcium, magnesium, and zinc contents of bones were determined. Deoxypyridinoline (a bone resorption marker) was measured in urine, and osteocalcin (a bone formation marker) was measured in serum. The calcium and phosphorus contents and bone mineral density were significantly higher in both femoral bones and L4 vertebra for phytate-treated rats in comparison to rats in the non-phytate group. Deoxypyridinoline was significantly increased in rats in the non-phytate treatment group. Ca-Mg-phytate consumption reduces bone mineral density loss due to estrogen deficiency. Thus, phytate exhibits effects similar to those of bisphosphonates on bone resorption and may be of use in the primary prevention of osteoporosis if larger studies in humans confirm these findings.

Bone mineral densities in patients with developmental dysplasia of the hip

Bone mineral density (BMD) of the lumbar spine, ultradistal radius, and calcaneus were significantly higher in the developmental dysplasia of the hip (DDH) patients than in the controls. Therefore, our data suggest that BMDs at different skeletal sites are greater in patients with DDH than in healthy women.

INTRODUCTION

DDH has been acknowledged as a potentially preosteoarthritic condition that results in the development of hip osteoarthritis. Patients with DDH have been reported to have abnormal morphology of the pelvis and spine. Additional research, including that of bone quality, needs to be conducted to elucidate the pathogenetic mechanism of this disease. We therefore sought to determine whether BMD differs between healthy women and women with DDH.

METHODS

We measured BMD in 40 women who were scheduled to undergo pelvic osteotomy for DDH (average age, 45.3 years) and in 31 healthy women used as age-matched controls (average age, 47.5 years). BMDs of the lumbar spine, radius, and calcaneus were measured.

RESULTS

BMDs of the lumbar spine, ultradistal radius, and calcaneus were significantly higher in the DDH patients than in the controls.

CONCLUSIONS

Therefore, our data suggest that BMDs at different skeletal sites are greater in patients with DDH than in healthy women.

Bone Mineral Density Is Not Related to Osteophyte Formation in Osteoarthritis of the Hip

Objective.

Reports have suggested that bone mineral density (BMD) is higher in patients with osteoarthritis (OA) of the hip than in healthy controls. Various types of OA of the hip caused by osteophyte formation were observed on radiographs during progression to the advanced degenerative stage, and the preoperative type of OA was reported to influence the results of surgical treatment. However, the mechanism underlying the development of different types of OA is still unknown. We measured BMD of patients with hip OA and determined whether higher BMD was observed in patients with osteophyte formation than in those without osteophytes.

Methods.

We measured BMD of the lumbar spine, radius, and calcaneus using dual-energy x-ray absorptiometry in 88 women who were scheduled to undergo total hip arthroplasty for endstage OA. Hips were evaluated for osteophyte formation using Bombelli’s classification; 31 were graded as atrophic type, 30 as normotrophic, and 27 as hypertrophic. BMD at different skeletal sites were compared among the 3 types of OA.

Results.

No significant difference in BMD of the lumbar spine, ultradistal radius, mid-radius, or calcaneus was observed among the atrophic, normotrophic, and hypertrophic types of OA.

Conclusion.

Our data suggest that osteophyte formation is not related to general BMD. Factors other than general bone status, for example the morphology of the hip joint, need to be analyzed to determine the pathomechanism of osteophyte formation in the osteoarthritic hip.

Management of osteoporosis in CKD Stages 3 to 5

Osteoporosis and chronic kidney disease (CKD) are both common conditions of older adults and both may be associated with substantial morbidity. However, biochemical and histologic changes that occur with progressive kidney disease require specific interventions, some of which may be concordant with osteoporosis management in the general population, whereas others may be less relevant or perhaps even harmful. In this article, we review the diagnosis of and management strategies for osteoporosis in individuals with CKD, placing these into perspective with the recently published KDIGO (Kidney Disease: Improving Global Outcomes) guidelines for treatment of CKD-mineral and bone disorder (CKD-MBD). Specifically, we highlight osteoporosis treatment recommendations by CKD stage and discuss new avenues for osteoporosis treatment that may be useful in individuals with CKD.

Male risk factors for hip fracture-a 30-year follow-up study in 7,495 men

SUMMARY

Risk factors for hip fracture were studied in 7,495 randomly selected men during 30 years; 451 men had a hip fracture. High degree of leisure-time, but not work-related, physical activity, high occupational class, and high body mass index (BMI) protected against hip fracture. Smoking, tall stature, interim stroke, and dementia increased the risk.

PURPOSE

The purpose was to prospectively study risk factors for hip fracture in men.

METHODS

We studied midlife determinants of future hip fractures in 7,495 randomly selected men aged 46-56 years in Gothenburg, Sweden. The subjects were investigated in 1970-1973 and followed for over 30 years. Questionnaires were used regarding lifestyle factors, psychological stress, occupational class, and previous myocardial infarction, stroke, and diabetes mellitus. Alcohol problems were assessed with the aid of registers. Using the Swedish hospital discharge register, data were collected on intercurrent stroke and dementia diagnoses and on first hip fractures (X-ray-verified).

RESULTS

Four hundred fifty-one men (6%) had a hip fracture. Age, tall stature, low occupational class, tobacco smoking, alcoholic intemperance, and interim stroke or dementia were independently associated with the risk of hip fracture. There were inverse associations with leisure-time physical activity, BMI, and coffee consumption. The gradient of risk for one standard deviation of multivariable risk decreased with time since measurement yet was a good alternative to dual energy X-ray absorptiometry measurements.

CONCLUSIONS

High degree of leisure-time physical activity, high occupational class, and high BMI protected against hip fracture. However, work-related physical activity was not protective. Smoking, tall stature, and interim stroke or dementia increased the risk.

Fracture prevention in men

The lifetime risk of experiencing a fracture in 50-year-old men is lower (20%) than the risk in women (50%). Consequently, much less research has been carried out on osteoporosis and fracture risk in men. Differences in the risk and incidence of fractures between men and women are related to differences in bone-related and fall-related factors between the sexes. During the past decade, progress has been achieved in case finding and fracture prevention in men. Epidemiology studies have better specified the prevalence and incidence of fractures, and insight into the pathophysiology of osteoporosis and fractures in men has progressed considerably. Case finding for men and women at the highest risk of fracture is now possible using the FRAX algorithm, which includes clinical risk factors, with and without bone mineral density, and allows calculation of an individual's 10-year fracture risk. Although strategies to prevent fractures are much less common in men than in women, several treatment options are now available for this purpose. Bisphosphonates, in particular, consistently demonstrate a positive effect on bone mineral density, and some data also indicate decreased rates of vertebral fractures. For men with severe osteoporosis, treatment with the anabolic agent teriparatide might be an effective option.

The burden of hospitalized hip fractures: patterns of admissions in a level I trauma center over 20 years

BACKGROUND

To describe trends over 20 years in (1) number of admissions for hip fracture, (2) patients' demographics, type of fractures sustained by the patients, and their health status at admission, (3) surgical delays, and (4) acute care outcomes.

METHODS

This trend was a study conducted in a Level I trauma center in Quebec, Canada. All patients (n = 3174) aged 65 and older, admitted with a hip fracture between 1985 and 2005 were included. Outcome measures were: number of admissions, age, gender, comorbidities at admission, surgical delays, postsurgical complications, inpatient mortality, discharge destinations.

RESULTS

From 1985 to 2005, the number of admissions increased from 56 to 271, age at admission has increased by 2 years both in men and women (p < 0.01), women/men proportion has remained stable (3.2) over time. The adjusted proportions of minor and severe comorbidities at admission increased by 13% and 5% yearly (p < 0.01). Surgical delays decreased from 4.7 days +/- 16.5 days to 0.9 days +/- 1.9 days (p < 0.01). Acute care length of stay has drastically decreased from 37.0 days +/- 70.9 days to 16.7 days +/- 14.2 days (p < 0.01). Although severe postsurgical complications did not increase over time, the proportion of patients suffering from minor postsurgical complications increased by 22%. Inpatient death has decreased by 4% each year.

CONCLUSION

The tremendous increase in the volume of older and sicker patients admitted for hip fracture has put an enormous demand on our Level I trauma center. The changes in clinical management implemented to face this challenge have helped improve acute care outcomes.

A new value of proximal femur geometry to evaluate hip fracture risk: true moment arm

This study was undertaken to determine the influence of proximal femur geometry on hip fracture risk independent of bone mineral density. We examined 34 hip fracture subjects (17 men, 17 women) and 36 control subjects (18 men, 18 women). The control subjects were matched with the hip fracture patients by femoral neck bone mineral density (+ or - 0.100 g/cm(2)). Hip axis length (HAL), femoral axis length (FAL), femoral neck-shaft angle (Theta angle), lateral and medial femoral cortical thickness were measured on standart pelvic radiographs. In the literature, there are conflicting views of the relationship between femur geometry and hip fracture risk which may be explained by different definitions of some parameters. We investigated the effect of a new parameter called true moment arm (TMA) on hip fracture risk. Longer TMA may be correlated to higher transmission of impact energy to the femoral neck. Thus it may be useful to define fracture prone individuals. The results of this study showed that HAL, FAL and TMA were significantly longer in the hip fracture subjects compared to the control group (p<0.001). Hip fracture patients had thinner lateral and medial femoral cortical thickness (p<0.001). Theta angle was wider in the hip fracture group than in the control group (p<0.001). In conclusion, our study showed that evaluation of TMA in addition to HAL, FAL, Theta angle, MCT and LCT can be used to determine of the fracture risk independently of BMD.

Phytate (myo-inositol hexaphosphate) and risk factors for osteoporosis

Several risk factors seem to play a role in the development of osteoporosis. Phytate is a naturally occurring compound that is ingested in significant amounts by those with diets rich in whole grains. The aim of this study was to evaluate phytate consumption as a risk factor in osteoporosis. In a first group of 1,473 volunteer subjects, bone mineral density was determined by means of dual radiological absorptiometry in the calcaneus. In a second group of 433 subjects (used for validation of results obtained for the first group), bone mineral density was determined in the lumbar column and the neck of the femur. Subjects were individually interviewed about selected osteoporosis risk factors. Dietary information related to phytate consumption was acquired by questionnaires conducted on two different occasions, the second between 2 and 3 months after performing the first one. One-way analysis of variance or Student's t test was used to determine statistical differences between groups. Bone mineral density increased with increasing phytate consumption. Multivariate linear regression analysis indicated that body weight and low phytate consumption were the risk factors with greatest influence on bone mineral density. Phytate consumption had a protective effect against osteoporosis, suggesting that low phytate consumption should be considered an osteoporosis risk factor.

Serum 25-hydroxyvitamin D and bone mineral density among Hispanic men

There are few data on the skeletal health of Hispanic men. We observed differences in vitamin D deficiency and low BMD between Hispanic ethnic subgroups that persisted with adjustment for risk factors. Our data indicate a substantial burden of low BMD and vitamin D deficiency among Hispanic men.

INTRODUCTION

Disparities within ethnic groups are generally ignored, but in evolving populations they may have implications for public health. We examined ethnic variation in serum 25-hydroxyvitamin D [25(OH)D] and bone mineral density (BMD) among Hispanic American men.

METHODS

Three hundred and fifty-eight Hispanic males 30 to 79 years of age were studied. Logistic regression models assessed variation in odds of vitamin D deficiency (<20 ng/mL) and low BMD (T-score<-1) by ethnicity, with and without adjustment for risk factors (age, smoking, occupation, physical activity, body mass index, and sunlight exposure).

RESULTS

Vitamin D deficiency was most common among Puerto Rican (26%), compared with Dominican (21%), Central American (11%), and South American (9%) men. Percentages with low BMD were: South American (44%), Puerto Rican (34%), Dominican (29%), and Central American (23%). Adjustment for age and risk factors failed to account for Hispanic subgroup differences in vitamin D deficiency and low BMD. Population estimates indicate a substantial burden of low BMD and vitamin D deficiency among Hispanic men.

CONCLUSIONS

Our findings underscore the importance of examining the skeletal health of Hispanic subgroups, and suggest that a considerable number of Hispanic men may be at elevated risk of fracture and vitamin D deficiency.

Osteoporosis in men

With the aging of the population, there is a growing recognition that osteoporosis and fractures in men are a significant public health problem, and both hip and vertebral fractures are associated with increased morbidity and mortality in men. Osteoporosis in men is a heterogeneous clinical entity: whereas most men experience bone loss with aging, some men develop osteoporosis at a relatively young age, often for unexplained reasons (idiopathic osteoporosis). Declining sex steroid levels and other hormonal changes likely contribute to age-related bone loss, as do impairments in osteoblast number and/or activity. Secondary causes of osteoporosis also play a significant role in pathogenesis. Although there is ongoing controversy regarding whether osteoporosis in men should be diagnosed based on female- or male-specific reference ranges (because some evidence indicates that the risk of fracture is similar in women and men for a given level of bone mineral density), a diagnosis of osteoporosis in men is generally made based on male-specific reference ranges. Treatment consists both of nonpharmacological (lifestyle factors, calcium and vitamin D supplementation) and pharmacological (most commonly bisphosphonates or PTH) approaches, with efficacy similar to that seen in women. Increasing awareness of osteoporosis in men among physicians and the lay public is critical for the prevention of fractures in our aging male population.

Isoflavones prevent bone loss following ovariectomy in young adult rats

Soy protein, a rich source of phytoestrogens, exhibit estrogen-type bioactivity. The purpose of this study was to determine if ingestion of isoflavones before ovariectomy can prevent bone loss following ovariectomy. Twenty-four nulliparous Wistar rats were randomly divided into four groups. In the normal diet groups, a sham operation was performed on Group A, while ovariectomy was performed on Group B. For Groups C and D, all rats were fed with an isoflavone-rich (25 mg/day) diet for one month, then bilateral ovariectomy were performed. In the rats in Group C, a normal diet was begun following the ovariectomy. The rats in Groups D continued to receive the isoflavone-rich diet for two additional months postoperatively. All rats were sacrificed 60 days after surgery. The weight of bone ash of the long bones and whole lumbar spine were determined. A histological study of cancellous bone was done and biochemical indices of skeletal metabolism were performed and analyzed. The markers of bone metabolism exhibited no significant changes. When compared with the sham-operated rats fed a normal diet, the bone mass of ovariectomized rats decreased significantly; pre-ovariectomy ingestion of an isoflavone-rich diet did not prevent bone loss. The bone mass of rats treated with an isoflavone-rich diet for three months was higher than controls two months after ovariectomy.

Dietary isoflavones did not prevent the development of post-ovariectomy bone loss, but long-term ingestion of an isoflavone-rich diet increased the bone mineral contents after ovariectomy in young rats.

Race/ethnic differences in bone mineral density in men

The epidemiology of osteoporosis in male and minority populations is understudied. We compared BMD in 1,209 Black, Hispanic, and White men. Black men exhibited higher BMD than Hispanic or White men. Age-related BMD decreases were greatest among Hispanic men. Results may help explain variation in hip fracture rates by race/ethnicity.

INTRODUCTION

The epidemiology of osteoporosis in male and minority populations is understudied. To address this concern, we conducted a study of skeletal health in a diverse population of adult males.

METHODS

A total of 367 Black, 401 Hispanic, and 451 White men aged 30-79 years were randomly sampled from Boston, MA. Bone densitometry (bone area (BA), bone mineral content (BMC), and bone mineral density (BMD)) at the whole body, hip, lumbar spine, and forearm was performed. Multiple regression analyses on 1,209 men with available data were used to describe race/ethnic group-specific means (height- and age-adjusted) and age trends (height-adjusted) in BMC, BA, and BMD. Results were weighted to represent the Boston male population aged 30-79 years.

RESULTS

Black men had greater BMC and BMD than Hispanic or White men. Femoral neck BMD was 5.6% and 13.3% higher in Black men than in Hispanic and White men, respectively. Differences between Hispanic and White subjects were restricted to the hip. Age-related declines in BMC and BMD were significantly steeper among Hispanic than Black or White men.

CONCLUSIONS

Differences in BMC and BMD could explain variation in fracture rates among Black, Hispanic, and White men. The steeper age-related BMD decline in Hispanic men is of particular concern.

Incidence of hip fracture over a 10-year period (1991-2000): reversal of a secular trend

INTRODUCTION

Hip fractures are a major cause of burden associated with osteoporosis in terms of mortality, disability, and costs. With the ageing of the population, a marked increase in the number of fractures is expected. Furthermore, many studies reveal an increase of the age-adjusted hip fracture incidence. We specifically examined secular changes in the incidence of hip fracture in women and men aged 50 years and over in the well-defined area of Geneva, Switzerland.

MATERIALS AND METHODS

All hip fractured patients were retrospectively identified from the computer medical records of the main hospital, which is receiving 95% of hip fractures occurring in a well-defined area.

RESULTS

From 1991 to 2000, 4115 hip fractures were recorded in 2981 women and 822 men with a mean age (+/-S.D.) of 83.1+/-8.9 and 78.3+/-11.6 years, respectively. A second hip fracture occurred in 276 women (9.3%) and 36 men (4.4%), on average 2.1+/-1.9 (median 1.44) years after the first event without gender difference. The overall incidence of hip fractures was 455 (95% CI: 439-471) per 100,000 person-years in women and 153 (95% CI: 143-163) in men. The number of hip fractures remained constant (412 (95% CI: 397-426)), but the mean age of these patients increased each year by 0.13 year in women (p=0.019) and by 0.04 year in men (NS). Furthermore, the age-adjusted incidence of hip fractures, standardized to the 2000 Geneva population, decreased significantly by 1.4% (95% CI: -2.6 to -0.1) per year in women (p=0.021), but remained stable in men (0.5% (95% CI: -1.7 to +2.8) per year, p=0.66). The overall female/male ratio of hip fracture incidence was 2.99 (95% CI: 2.80-3.18, p<0.001) and significantly decreased by 0.07 (95% CI: -0.13 to -0.01) per year (p=0.024).

CONCLUSION

Despite an increase in the population at risk and in the mean age of hip fractured women, there was a significant decrease in age-adjusted incidence in women but not in men. These results may suggest a reversal of the previously observed secular trend.

Epidemiology of hip fractures in Belgrade, Serbia Montenegro, 1990-2000

INTRODUCTION

This study retrospectively determined the incidence rates of hip fractures in Belgrade, Serbia and Montenegro, during the period 1990-2000.

MATERIALS AND METHODS

All patients with hip fractures treated at all Belgrade hospitals were identified from the Republic of Serbia's Ministry of Health National Health Care database. Patient demographics, type of hip fracture, and details of the mechanism of injury were collected. The annual incidence rates were calculated with interpolation according to the Belgrade population census of 1991 and 2002.

RESULTS

There were a total of 8,904 hip fractures with a mean annual incidence of 51.7 per 100,000 adults (62.2 females and 35.5 males). Mean age at the time of fracture was 67 years (72.6 for females and 59.3 for males), with 64.7% of all fractures occurring in women. There was a significant increase in hip fracture incidence rates over the observed period in females (P = 0.006), but not in males (P = 0.962). Trochanteric fractures predominated, accounting for 53% compared with cervical fractures. In patients over 50 years of age there was an exponential increase in the incidence of hip fractures in both sexes; though more so in females. 91% of hip fractures occurred in these older patients with incidence rates of 143.6 per 100,000 (185.9 for female and 92.2 for male patients). The most common mechanism of injury in the older group was low-energy trauma (70.3%) resulting from a fall from standing height onto a flat surface (same level). Standardizing incidence rates in the older age group to the US 1985 white population gave values of 228 per 100,000 females and 96 per 100,000 males. These incidence rates are similar to those reported in Italy, France and Great Britain, but lower than those in Scandinavian countries.

CONCLUSION

In view of growing population numbers and an increase in the proportion of patients aged over 60 years, we can expect an increase in the prevalence of osteoporosis and an increase in the incidence of fragility hip fractures in the future, with resource implications.

Diet, nutrition and the prevention of osteoporosis

Objective:

To review the evidence on diet and nutrition relating to osteoporosis and provide recommendations for preventing osteoporosis, in particular, osteopototic fracture.

Approach:

Firstly, to review the definition, diagnosis and epidemiology of osteoporosis, to discuss the difficulties in using bone mineral density to define osteoporosis risk in a world-wide context and to propose that fragility fracture should be considered as the disease endpoint. Secondly, to provide an overview of the scientific data, the strengths and weaknesses of the evidence and the conceptual difficulties in interpreting studies linking diet, nutrition and osteoporosis. The following were considered: calcium, vitamin D, phosphorus, magnesium, protein and fluorine. Other potential dietary influences on bone health were also discussed, including vitamins, trace elements, electrolytes, acid–base balance, phyto-oestrogens, vegetarianism and lactose intolerance.

Conclusions:

There is insufficient knowledge linking bone mineral status, growth rates or bone turnover in children and adolescents to long-term benefits in old age for these indices to be used as markers of osteoporotic disease risk. For adults, the evidence of a link between intakes of any dietary component and fracture risk is not sufficiently secure to make firm recommendations, with the exception of calcium and vitamin D. For other aspects of the diet, accumulating evidence suggests that current healthy-eating advice to decrease sodium intake, to increase potassium intake, and to consume more fresh fruits and vegetables is unlikely to be detrimental to bone health and may be beneficial.

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.