Non-hip, non-spine fractures drive healthcare utilization following a fracture: the Global Longitudinal Study of Osteoporosis in Women (GLOW)

Costs of incident non-hip osteoporosis-related fractures in postmenopausal women from a payer perspective

Osteoporosis-related fractures lead to high morbidity, mortality, and healthcare costs among post-menopausal women. This study showed that incident non-hip osteoporosis-related fractures are frequent among women aged 50 + in Portugal, leading to excessive healthcare costs of €74 million per year, in a conservative scenario.

PURPOSE

This study aimed to estimate the costs of incident non-hip osteoporosis-related fractures among postmenopausal women living in Portugal from a payer perspective.

METHODS

The study includes women ≥ 50 years old who participated in the baseline assessment (2011-2013) and the first follow-up wave (2013-2015) of the Epidemiology of Chronic Diseases cohort, a Portuguese community-based longitudinal prospective study (n = 2,762). Incident non-hip osteoporosis-related fractures were defined as any self-reported low impact non-hip fractures since baseline. Healthcare resource utilization during the year following fracture was obtained from an informal panel of experts. The amounts of resources used were multiplied by the national tariffs practiced in the National Health Service (NHS) to obtain the cost per patient in the year following a wrist, vertebral, or other site fracture, which was subsequently multiplied by the estimated annual number of incident fractures to obtain the total annual cost of incident non-hip osteoporosis-related fractures among postmenopausal women.

RESULTS

Each year approximately 5,000 wrist, 3,500 vertebral, and 39,000 other-site osteoporosis-related fractures occur in women aged 50 + in Portugal. Healthcare costs per patient in the year following fracture vary from €2,709.52 for vertebral fractures to €3,096.35 for other fractures. Non-hip incident osteoporosis-related fractures among 50 + women cost approximately €74 million per year. Among all healthcare services, physiotherapy represents the bulk of costs.

CONCLUSIONS

This study pinpoints the relevance of preventing non-hip osteoporosis-related fractures, as these cost about €74 million per year in direct healthcare costs, a substantial impact on the budget of the Portuguese NHS.

Development and validation of common data model-based fracture prediction model using machine learning algorithm

The need for an accurate country-specific real-world-based fracture prediction model is increasing. Thus, we developed scoring systems for osteoporotic fractures from hospital-based cohorts and validated them in an independent cohort in Korea. The model includes history of fracture, age, lumbar spine and total hip T-score, and cardiovascular disease.

PURPOSE

Osteoporotic fractures are substantial health and economic burden. Therefore, the need for an accurate real-world-based fracture prediction model is increasing. We aimed to develop and validate an accurate and user-friendly model to predict major osteoporotic and hip fractures using a common data model database.

METHODS

The study included 20,107 and 13,353 participants aged ≥ 50 years with data on bone mineral density using dual-energy X-ray absorptiometry from the CDM database between 2008 and 2011 from the discovery and validation cohort, respectively. The main outcomes were major osteoporotic and hip fracture events. DeepHit and Cox proportional hazard models were used to identify predictors of fractures and to build scoring systems, respectively.

RESULTS

The mean age was 64.5 years, and 84.3% were women. During a mean of 7.6 years of follow-up, 1990 major osteoporotic and 309 hip fracture events were observed. In the final scoring model, history of fracture, age, lumbar spine T-score, total hip T-score, and cardiovascular disease were selected as predictors for major osteoporotic fractures. For hip fractures, history of fracture, age, total hip T-score, cerebrovascular disease, and diabetes mellitus were selected. Harrell's C-index for osteoporotic and hip fractures were 0.789 and 0.860 in the discovery cohort and 0.762 and 0.773 in the validation cohort, respectively. The estimated 10-year risks of major osteoporotic and hip fractures were 2.0%, 0.2% at score 0 and 68.8%, 18.8% at their maximum scores, respectively.

CONCLUSION

We developed scoring systems for osteoporotic fractures from hospital-based cohorts and validated them in an independent cohort. These simple scoring models may help predict fracture risks in real-world practice.

Posterior pelvic ring involvement detected with CT taken within a week of admission in acute fragility fractures of the pelvis (FFP) does not predict failure of conservative treatment: a retrospective cohort study

BACKGROUND

Acute low energy pubic rami fractures in the elderly receive primarily conservative treatment. There is debate to what extent posterior ring involvement, which is detected superiorly by CT compared to X-ray, has an impact on outcome and may require modified treatment. We want to demonstrate if posterior ring involvement has an influence on different types of outcome in primarily conservatively treated acute FFP, questioning the usefulness of early CT. Additionally we analysed the early fracture pattern in cases where conservative treatment failed with need for secondary surgery.

METHODS

A retrospective cohort study of 155 consecutive patients, recruited between 2009 and 2016, aged over 65 years diagnosed with an acute LE-PFr on X-ray at the emergency department of a single, level-one trauma centre and receiving an early CT. A set of outcome parameters was compared between patients with an isolated pubic rami fracture (CTia) and patients who had a combined posterior pelvic ring fracture (CTcp).

RESULTS

There were 155 patients of whom 85.2% were female with a mean age of 83 years. 76.8% of patients living at home returned home and 15.5% moved to a nursing home. Mortality rate during hospitalisation was 6.4% and 14.8% at one year post-trauma. Secondary fracture displacement occurred in 22.6%. Secondary surgery was performed in 6 cases (3.9%). Median hospitalisation length of stay was 21 days (range 0 to 112 days). There was no significant association between the subgroups and change in residential status (p = 0.65), complications during hospitalisation (p = 0.75), mortality rate during admission (p = 0.75) and at 1 year (p = 0.88), readmission within 30 days (p = 0.46) and need for secondary surgery (p = 0.2). There was a significant increased median length of stay (p = 0.011) and rate of secondary displacement (p = 0.015) in subgroup CTcp. Secondary displacement had no impact on in-hospital complications (p = 0.7) nor mortality rate during admission (p = 0.79) or at 1 year (0.77). Early CT in patients who underwent secondary surgery showed stable B2.1 lesions in 4 of 6 cases.

CONCLUSIONS

Our data suggest that early CT in patients with conservatively treated acute LE-PFr in order to detect posterior lesions, has limited value in predicting failure of conservative treatment.

Overall Effects and Moderators of Rehabilitation in Patients With Wrist Fracture: A Systematic Review

OBJECTIVE

Wrist fractures constitute the most frequently occurring upper limb fracture. Many individuals report persistent pain and functional limitations up to 18 months following wrist fracture. Identifying which individuals are likely to gain the greatest benefit from rehabilitative treatment is an important research priority. This systematic review aimed to summarize effectiveness of rehabilitation after wrist fracture for pain and functional outcomes and identify potential effect moderators of rehabilitation.

METHODS

A comprehensive search of 7 databases (including MEDLINE, EMBASE, and the Physiotherapy Evidence Database) was performed for randomized controlled trials involving adults >50 years of age who sustained wrist fracture and had received 1 or more conservative treatments (eg, exercise/manual therapy, lifestyle, diet, or other advice). Study selection, data extraction, and risk-of-bias assessment were conducted independently by 2 reviewers. Results of included trials were summarized in a narrative synthesis.

RESULTS

A total of 3225 titles were screened, and 21 studies satisfying all eligibility criteria were reviewed. Over one-half of the included studies (n = 12) comprised physical therapist and/or occupational therapist interventions. Rehabilitative exercise/manual therapy was generally found to improve function and reduce pain up to 1 year after wrist fracture. However, effects were small, and home exercises were found to be comparable with physical therapist-led exercise therapy. Evidence for the effects of other nonexercised therapy (including electrotherapy, whirlpool) was equivocal and limited to the short term (<3 months). Only 2 studies explored potential moderators, and they did not show evidence of moderation by age, sex, or patient attitude of the effects of rehabilitation.

CONCLUSION

Effectiveness of current rehabilitation protocols after wrist fracture is limited, and evidence for effect moderators is lacking. Currently available trials are not large enough to produce data on subgroup effects with sufficient precision. To aid clinical practice and optimize effects of rehabilitation after wrist fracture, potential moderators need to be investigated in large trials or meta-analyses using individual participant data.

IMPACT

Many patients report persistent pain and functional limitations up to 18 months following wrist fracture. Effectiveness of current rehabilitation protocols after wrist fracture is limited and may be due to insufficient targeting of specific rehabilitation to individuals who are likely to benefit most. However, evidence for effect moderators is lacking within the currently available literature. To aid clinical practice and optimize effects of rehabilitation, investigating potential moderators of rehabilitation in individuals with wrist fracture via large trials or meta-analysis of individual participant data is research and policy imperative.

Long-term clinical and socio-economic outcomes following wrist fracture: a systematic review and meta-analysis

A comprehensive review of studies shows that patients with wrist fracture, aged over 50 years, experience pain and functional limitation long after fracture. This is associated with increased healthcare costs, and reduced quality of life. Understanding factors that predict poor outcomes is important for future healthcare policy and planning.

PURPOSE

To summarise and appraise evidence on the prognosis and long-term clinical and socio-economic outcomes following wrist fracture among adults aged 50 years and over.

METHODS

Five databases (MEDLINE, EMBASE, AMED, CINAHL-P and PsycINFO) were comprehensively searched (supplemented by a grey-literature search) from inception till June 2021 for prospective/retrospective cohort studies of patients (≥ 50 years) with a history of wrist fracture and reporting long-term (≥ 6 months) outcomes. Peer study selection, data extraction and risk of bias assessment were conducted. A random effects meta-analysis was used to summarise estimates of pain and function outcomes.

RESULTS

78 studies (n = 688,041 patients) were included. Patients report persistent moderate to severe pain (range: 7.5%-62%) and functional limitations (range: 5.5-78%) up to 12-months or later after wrist fracture. Mean Patient-Rated Wrist Evaluation (PRWE) score for pain and function (9 studies, n = 1759 patients) was 15.23 (95%CI 12.77, 17.69) at 6-months to 13-years follow-up. Mean disabilities of the arm, shoulder and hand (DASH) score (9 studies, n = 1346 patients) was 13.82 (95%CI 12.71, 14.93)( at 6- to 17-months follow-up. A 10-20% increase in healthcare encounters in the first 12-months after fracture was observed. Twelve prognostic factors were associated with poor long-term outcomes.

CONCLUSION

Evidence shows that a high proportion of people aged over 50 years with wrist fracture experience pain and functional limitation > 6 months after fracture. This is associated with increased healthcare costs, and reduced quality of life. Exploratory evidence was found for several candidate prognostic factors. Their predictive performance needs to be investigated further.

PROSPERO

CRD42018116478.

Incidence and risk factors for osteoporotic non-vertebral fracture in low-income community-dwelling elderly: a population-based prospective cohort study in Brazil. The São Paulo Ageing and Health (SPAH) study

We ascertained the incidence of non-vertebral fracture in a low-income Brazilian elderly cohort. To the best of our knowledge, this is the first population-based study to demonstrate the frequency of non-vertebral fracture in elderly Latin Americans. Age, prior fracture, and bone mineral density (BMD) at hip were predictors of fracture.

INTRODUCTION

No data on incidence of osteoporotic non-vertebral fracture have been reported in low-income countries where the population's aging has been faster. Even in developed countries, currently available prospective data on major fracture rates beyond hip are scarce. The aim of this study is to describe the incidence and risk factors for non-vertebral fracture in a longitudinal prospective Brazilian population-based elderly cohort.

METHODS

Seven hundred seven older adults (449 women, 258 men) were evaluated at baseline and after a mean follow-up of 4.3 ± 0.8 years. Clinical questionnaire, bone mineral density (BMD), and laboratory tests were performed at baseline. New non-vertebral fracture (hip, proximal humerus, rib, forearm) was determined during the follow-up. Multivariate Poisson regression models were used to identify independent predictors of fracture.

RESULTS

The age-standardized incidence of non-vertebral fracture was 1562.3/100,000 (1085.7-2248.1/100,000) person-years (pyr) in women and 632.8/100,000 (301.7-1327.3/100,000) in men. Concerning to hip fractures, the incidence was 421.2/100,000 (210.7-842.3/100,000) pyr in women and 89.9/100,000 (12.7-638.5/100,000) in men. In a multivariate analysis, age (RR 2.07, 95% CI 1.13-3.82, p = 0.019, each 10-year increase), prior non-vertebral fracture (RR 3.08, 95% CI 1.36-6.95, p = 0.007), and total hip BMD (RR 1.68, 95% CI 1.11-2.56, p = 0.015, each 1 SD decrease) were predictors of new non-vertebral fracture. In men, fitting a model of risk factors for fracture was prevented by the limited number of events in male sample.

CONCLUSION

This is the first population-based study to ascertain the incidence of major non-vertebral fractures in elderly Latin Americans, confirming the high frequency of the disorder. Age, prior fracture, and hip BMD were predictors of the short-term incidence of fracture.

Validation of the FRAiL model to predict non-vertebral and hip fractures in nursing home residents

OBJECTIVE

Tools were unavailable to assess fracture risk in nursing homes (NH); therefore, we developed the Fracture Risk Assessment in Long term care (FRAiL) model. The objective of this validation study was to assess the performance of the FRAiL model to predict 2-year risk of non-vertebral and hip fractures in a separate large cohort of NH residents.

METHODS

This retrospective cohort study included most long-stay NH residents in the United States (N = 896,840). Hip and non-vertebral fractures were identified using Medicare claims. The Minimum Data Set (MDS) was used to identify characteristics from the original FRAiL model. Multivariable competing risk regression was used to model risk of fracture.

RESULTS

Mean age was 83.8 years (±8.2 years) and 70.7% were women. Over a mean follow-up of 1.52 years (SD 0.65), 41,531 residents (4.6%) were hospitalized with non-vertebral fracture (n = 30,356 hip fractures). In the fully adjusted model, 14/15 model characteristics remained significant predictors of non-vertebral fracture. Female sex (HR = 1.55, 95% CI 1.52, 1.59), wandering (HR = 1.30, 95% CI 1.26, 1.34), and falls (HR = 1.28, 95% CI 1.26, 1.31) were strongly associated with non-vertebral fracture rate. Total dependence in ADLs (versus independence) was associated with a decrease in non-vertebral fracture rate (HR = 0.57, 95% CI 0.52, 0.64). Discrimination was moderate in men (C-index = 0.68 for hip, 0.66 for non-vertebral) and women (C-index = 0.68 for hip, 0.65 for non-vertebral), and calibration was excellent.

CONCLUSIONS

Our model comprised entirely from routinely collected data was able to identify NH residents at greatest risk for non-vertebral fracture.

A new noninvasive mechanical bending test accurately predicts ulna bending strength in cadaveric human arms

BACKGROUND

High error rates in the prediction of fragility fractures by bone mineral density have motivated searches for better clinical indicators of bone strength, and the high incidence of non-hip, non-spine fractures has raised interest in cortical bone. The aim of this study was to assess the accuracy of Cortical Bone Mechanics Technology™. CBMT is a new non-invasive 3-point bending technique for measuring the mechanical properties of cortical bone in the ulnas of living humans.

METHODS

35 cadaveric human arms were obtained from small women and large men ranging widely in age (17 < Age < 99 years) and body size (14 < BMI < 40 kg/m²). Noninvasive CBMT measurements of the flexural rigidity of the ulna bones within these arms (EI_CBMT) were compared to measurements of EI by Quasistatic Mechanical Testing in the ulnas excised from those arms (EI_QMT). Ulna bending strength was also measured by QMT as the peak moment before fracture (M_peak). The open source BoneJ plugin to ImageJ image processing software was used to calculate cortical porosity (CP) in micro-computed tomography images of a 2 mm length of the mid-shaft of each fractured ulna, and the interosseous diameter (IOD) of each ulna was also measured in those images.

RESULTS

EI_CBMT measurements (13 < EI_CBMT < 97 Nm²) explained 99% of the variance in QMT measurements of ulna bending strength (11 < M_peak < 90 Nm), but EI_CBMT was biased high by 30% (p < 0.0001) relative to EI_QMT (11 < EI_QMT < 69 Nm²). After correcting this bias, EI_CBMT and EI_QMT measurements lay along the identity line (y = 1.00x, R² = 0.99, SEE = 3.1 Nm²). Predictions of M_peak by EI_CBMT were less accurate than predictions by EI_QMT (both R² = 0.99; SEE_CBMT = 5.9 Nm vs SEE_QMT = 4.5 Nm, F = 2.92, p = 0.001), but EI_CBMT predictions were substantially more accurate than those by IOD (R² = 0.79; SEE_IOD = 10.6 Nm, F = 3.30, p < 0.001) and CP (R² = 0.35; SEE_CP = 18.9 Nm, F = 10.45, p < 10^-9). Predictions by EI_CBMT were also more accurate than predictions by arm donor height (R² = 0.63; SEE = 14.3 Nm, F = 5.87, p < 10^-6), body weight (R² = 0.77; SEE = 11.1 Nm, F = 3.54, p < 0.001) and BMI (R² = 0.64; SEE = 14.1 Nm, F = 2.39, p < 0.01). In forward stepwise multiple regression beginning with EI_CBMT, only age explained any additional variance in ulna bending strength (ΔR² = 0.3%, F = 8.03, p = 0.008).

CONCLUSION

Noninvasive CBMT measurements of ulna EI explain 99% of individual differences in QMT measurements of ulna bending strength in cadaveric human arms.

Self-reported low-energy fractures and associated risk factors in people with diabetes: A national population-based study

AIMS

Clinical risk factors and bone mineral densitometry underestimate low-energy fracture (LEF) risk in people with diabetes. We aim to estimate the prevalence of LEF in diabetics, compare with nondiabetics; and evaluate possible predictors of LEF in people with diabetes.

METHODS

Cross-sectional, population-based study in Portuguese subjects over 40 years-old. Estimates computed as weighted proportions/means, considering sample design. Multivariate logistic regression models to evaluate the association of diabetes and LEF; and predictors of LEF in diabetics.

RESULTS

7675 subjects were analysed, of which 1173 reported diabetes. Diabetics were older (mean age 66.0 ± 11.49y), more frequently reported osteoporosis and falls in the previous 12 months (32.4% vs. 22.9%). Prevalence of self-reported LEF was 16.2% (95% CI:13.68-19.13) among diabetics (vs. 13.3%, 95% CI:12.14-14.57, in nondiabetics); OR for the association diabetes and LEF:1.26, 95% CI:1.01-1.58, p = 0.045 (in women, adjusted OR:1.41, 95% CI:1.05-1.89, p = 0.02). Thirty percent of diabetics reported at least one major LEF and 70% in other sites. In diabetics, LEF was independently associated with self-reported osteoporosis and falls in the previous 12 months.

CONCLUSION

People with diabetes reported more falls and had higher prevalence of self-reported LEF. Self-reported osteoporosis and falls were associated with LEF in diabetics. Our findings emphasize the need for fracture and falls preventive measures in diabetics.

Fracture incidence and secular trends between 1989 and 2013 in a population based cohort: The Rotterdam Study

Fracture incidence needs to be evaluated over time to assess the impact of the enlarging population burden of fractures (due to increase in lifespan) and the efficacy of fracture prevention strategies. Therefore, we aimed to evaluate the association of femoral neck bone mineral density (FN-BMD) measured using dual-energy X-ray absorptiometry (DXA) at baseline with fracture risk over a long follow-up time period. Incident non-vertebral fractures were assessed in 14,613 individuals participating in the Rotterdam Study with up to 20 years of follow-up. During a mean follow-up of 10.7 ± 6.2 years, 2971 (20.3%) participants had at least one incident non-vertebral fracture. The risk for any non-vertebral fracture was 1.37 (95% Confidence Interval (CI): 1.25-1.49) and 1.42 (95%CI: 1.35-1.50) for men and women, respectively. The majority (79% in men and 75% in women) of all fractures occurred among participants a normal or osteopenic T-score. The incidence rates per 1000 person-years for the most common fractures were 5.3 [95%CI: 5.0-5.7] for hip, 4.9 [95%CI: 4.6-5.3] for wrist and 2.3 [95%CI: 2.0-2.5] for humerus. To examine the predictive ability of BMD through follow-up time we determined fracture hazard ratios (HR) per standard deviation decrease in femoral neck BMD across five year bins. No differences were observed, with a HR of 2.5 (95%CI: 2.0-3.1) after the first 5 years, and of 1.9 (95%CI: 1.1-3.3) after 20 years. To assess secular trends in fracture incidence at all skeletal sites we compared participants at an age of 70-80 years across two time periods: 1989-2001 (n = 2481, 60% women) and 2001-2013 (n = 2936, 58% women) and found no statistically significant difference (p < 0.05) between fracture incidence rates (i.e., incidence of non-vertebral fractures of 26.4 per 1000 PY [95%CI: 24.4-28.5]) between 1989 and 2001, and of 25.4 per 1000 PY [95%CI: 23.0-28.0] between 2001 and 2013. In conclusion, BMD is still predictive of future fracture over a long period of time. While no secular changes in fractures rates seem to be observed after a decade, the majority of fractures still occur above the osteoporosis threshold, emphasizing the need to improve the screening of osteopenic patients.

The burden and undertreatment of fragility fractures among senior women

Using a large population database, we showed that fragility fractures were highly prevalent in senior women and were associated with significant physical disability. However, treatment rates were low because osteoporosis treatment was not prescribed or not agreed to by the majority of women with prevalent fragility fractures.

PURPOSE

The purpose of the study is to estimate prevalence of fragility fractures (FF), risk factors, and treatment rates in senior women and to assess impact of FF on physical function and quality of life.

METHODS

Women aged 65 years and older from the EpiReumaPt study (2011-2013) were evaluated. Rheumatologists collected data regarding FF, clinical risk factors for fractures, and osteoporosis (OP) treatment. Health-related quality of life (EQ5D) and physical function (HAQ) were analyzed. Peripheral dual-energy X-ray absorptiometry was performed. FF was defined as any self-reported low-impact fracture that occurred after 40 years of age. Prevalence estimates of FF were calculated.

RESULTS

Among 3877 subjects evaluated in EpiReumaPt, 884 were senior women. The estimated prevalence of FF was 20.7%. Lower leg was the most frequent fracture site reported (37.8%) followed by wrist (18.6%). Only 7.1% of the senior women reporting a prevalent FF were under treatment for OP, and 13.9% never had treatment. OP treatment was not prescribed in 47.7% of FF women, and 23.4% refused treatment. Age (OR = 2.46, 95% CI 1.11-5.47), obesity (OR = 2.05, 95% CI 1.14-3.70), and low wrist BMD (OR = 2.29; 95% CI 1.20, 4.35; p = 0.012) were positively associated with prevalent FF. A significantly higher proportion of women in the lowest quintile of wrist bone mineral density reported FF (OR = 2.29, 95% CI 1.20-4.35). FF were associated with greater physical disability (β = 0.33, 95% CI 0.13-0.51) independent of other comorbidities.

CONCLUSION

FF was frequently reported among senior women as an important cause of physical disability. However, the prevalence of OP treatment was low, which constitutes a public health problem in this vulnerable group.

Identification and management of patients at increased risk of osteoporotic fracture: outcomes of an ESCEO expert consensus meeting

Osteoporosis represents a significant and increasing healthcare burden in Europe, but most patients at increased risk of fracture do not receive medication, resulting in a large treatment gap. Identification of patients who are at particularly high risk will help clinicians target appropriate treatment more precisely and cost-effectively, and should be the focus of future research.

INTRODUCTION

The purpose of the study was to review data on the identification and treatment of patients with osteoporosis at increased risk of fracture.

METHODS

A working group convened by the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis met to review current data on the epidemiology and burden of osteoporosis and the patterns of medical management throughout Europe.

RESULTS

In Europe in 2010, the cost of managing osteoporosis was estimated at €37 billion and notably the costs of treatment and long-term care of patients with fractures were considerably higher than the costs for pharmacological prevention. Despite the availability of effective treatments, the uptake of osteoporosis therapy is low and declining, in particular for secondary fracture prevention where the risk of a subsequent fracture following a first fracture is high. Consequently, there is a significant treatment gap between those who would benefit from treatment and those who receive it, which urgently needs to be addressed so that the burden of disease can be reduced.

CONCLUSIONS

Implementation of global fracture prevention strategies is a critical need. Future research should focus on identifying specific risk factors for imminent fractures, periods of high fracture risk, patients who are at increased risk of fracture and therapies that are most suited to such high-risk patients and optimal implementation strategies in primary, secondary and tertiary care.

Role of cortical bone in bone fragility

PURPOSE OF REVIEW

Trabecular bone loss and vertebral fractures are historical hallmarks of osteoporosis. During the past 70 years, this view has dominated research aiming to understand the structural basis of bone fragility. We suggest this notion needs to be revised to recognize and include the role of cortical bone deterioration as an important determinant of bone strength throughout life.

RECENT FINDINGS

About 80% of the fragility fractures involve the appendicular skeleton, at regions comprising large amounts of cortical bone. Up to 70% of the age-related bone loss at these locations is the result of intracortical remodeling that cavitates cortical bone producing porosity. It is now possible to accurately quantify cortical porosity in vivo and use this information to understand the pathogenesis of bone fragility throughout life, assist in identifying patients at risk for fracture, and use this as a potential marker to monitor the effects of treatment on bone structure and strength.

SUMMARY

Cortical bone has an important role in determining bone strength. The loss of strength is the result of intracortical and endocortical remodeling imbalance that produces cortical porosity and thinning. Studies are needed to determine whether porosity is an independent predictor of fracture risk and whether a reduction in porosity serves as a surrogate of antifracture efficacy.

The mortality and direct medical costs of osteoporotic fractures among postmenopausal women in Taiwan

This study estimated the fracture-related mortality and direct medical costs among postmenopausal women in Taiwan by fracture types and age groups by utilizing a nationwide population-based database. Results demonstrated that hip fractures constituted the most severe and expensive complication of osteoporosis across fracture sites.

INTRODUCTION

The aims of the study were to evaluate the risk of death and direct medical costs associated with osteoporotic fractures by fracture types and age groups among postmenopausal women in Taiwan.

METHODS

This nationwide, population-based study was based on data from the National Health Insurance Research Database in Taiwan. Female patients aged 50 years and older in the fracture case cohort were matched in 1:1 ratio with randomly selected subjects in the reference control cohort by age, income-related insurance amount, urbanization level, and the Charlson comorbidity index. There were two main outcome measures of the study: age-differentiated mortality and direct medical costs in the first and subsequent years after osteoporotic fracture events among postmenopausal women. The bootstrap method by resampling with replacement was conducted to generate descriptive statistics of mortality and direct medical costs of the case and control cohorts. Student's t tests were then performed to compare mortality and costs between the two cohorts.

RESULTS

A total of 155,466 postmenopausal women in the database met the inclusion criteria for the fracture case cohort, including 22,791 hip fractures, 72,292 vertebral fractures, 15,621 upper end humerus (closed) fractures, 36,774 wrist fractures, and 7,988 multiple fractures. Analytical results demonstrated that patients experiencing osteoporotic fractures were at considerable excess risk of death and incurred substantially higher treatment costs, notably for hip fractures. Furthermore, results also revealed that the risk of mortality increased with advancing age across the spectrum of fracture sites.

CONCLUSIONS

The present study confirmed an excess mortality and higher direct medical costs associated with osteoporotic fractures. Moreover, hip fractures constituted the most severe and expensive complication of osteoporosis among fracture types.

Impact of hip fracture on hospital care costs: a population-based study

Using a large cohort of hip fracture patients, we estimated hospital costs to be £14,163 and £2139 in the first and second year following fracture, respectively. Second hip and non-hip fractures were major cost drivers. There is a strong economic incentive to identify cost-effective approaches for hip fracture prevention.

INTRODUCTION

The purpose of this study was to estimate hospital costs of hip fracture up to 2 years post-fracture and compare costs before and after the index fracture.

METHODS

A cohort of patients aged over 60 years admitted with a hip fracture in a UK region between 2003 and 2013 were identified from hospital records and followed until death or administrative censoring. All hospital records were valued using 2012/2013 unit costs, and non-parametric censoring methods were used to adjust for censoring when estimating average annual costs. A generalised linear model examined the main predictors of hospital costs.

RESULTS

A cohort of 33,152 patients with a hip fracture was identified (mean age 83 years (SD 8.2). The mean censor-adjusted 1- and 2-year hospital costs after index hip fracture were £14,163 (95 % confidence interval (CI) £14,008 to £14,317) and £16,302 (95 % CI £16,097 to £16,515), respectively. Index admission accounted for 61 % (£8613; 95 % CI £8565 to £8661) of total 1-year hospital costs which were £10,964 higher compared to the year pre-event (p < 0.001). The main predictors of 1-year hospital costs were second hip fracture, other non-hip fragility fractures requiring hospitalisation and hip fracture-related complications. Total UK annual hospital costs associated with incident hip fractures were estimated at £1.1 billion.

CONCLUSIONS

Hospital costs following hip fracture are high and mostly occur in the first year after the index hip fracture. Experiencing a second hip fracture after the index fracture accounted for much of the increase in costs. There is a strong economic incentive to prioritise research funds towards identifying the best approaches to prevent both index and subsequent hip fractures.

Mason type II and III radial head fracture in patients older than 65: is there still a place for radial head resection?

PURPOSE

To evaluate the clinical outcomes of radial head excision for multifragmentary radial head fracture in patients over 65 years old.

METHODS

We retrospectively examined 30 patients over 65 years of age treated with radial head excision for comminuted radial head fractures. Patients were evaluated through clinical examinations, administrative questionnaires (DASH--Disabilities of the Arm, Shoulder and Hand; MEPS--Mayo Elbow Performance Score, VAS--Visual Analog Scale) and plain films.

RESULTS

The mean follow-up was 40 months (range 24-72 months); 27 out of 30 patients claimed to be satisfied. The mean DASH score was 13 (range 3-45.8) and mean MEPS was 79 (range 65-97). The radiographic evaluation showed 21 cases of elbow arthritis; only two of them complained about pain. Heterotopic ossification was evident in six cases with functional impairment in only one patient. Six patients with increased ulnar variance had clinical distal radio-ulnar joint instability.

DISCUSSION

Radial head excision has been considered a safe surgical procedure with satisfactory clinical outcomes. Development in biomechanical studies and prosthetic replacement of the radial head question the validity of radial head excision. In current literature, there are neither long-term follow-up studies on radial head prosthesis outcomes nor studies which consider elderly patient samples.

CONCLUSION

Radial head resection remains a good option when a radial head fracture occurs in elderly patients, taking into account the influence of poor bone quality and comorbidities on the outcome. Radial head excision is not indicated in the presence of associated lesions, because of the risk of residual elbow instability; complications associated with advanced age must be considered and a strict follow-up granted.

Osteoporosis epidemiology 2013: implications for diagnosis, risk assessment, and treatment

PURPOSE OF REVIEW

To summarize the recently published studies that provide insights into the changing epidemiology of osteoporosis and fractures.

RECENT FINDINGS

The main themes reviewed are fracture outcomes; trends in fractures rates; fracture risk assessment and monitoring; atypical femoral fractures; male osteoporosis; falls and physical activity; and sarcopenia, obesity, and metabolic syndrome.

SUMMARY

Osteoporotic fractures were found to have long-term consequences on excess mortality (10 years) and economic costs (5 years). The large burden of nonhip nonvertebral fractures has been underestimated. Divergent (but mostly declining) trends in fracture rates were confirmed in several cohorts from around the world. This has significant implications for healthcare planners and clinicians responsible for the care of individuals with osteoporosis, and also impacts on the calibration of fracture prediction tools. Although fracture prediction tools differ in their complexity, performance characteristics are similar when applied to the general population. Large, high-quality comparative studies with different case mixes are needed. Fracture probability does not appear to be responsive enough to support goal-directed treatment at this time. A consensus on the diagnosis of osteoporosis in men has emerged, based upon the same absolute bone density cutoff for both men and women. Finally, a plethora of new data highlight the importance of falls, physical activity, and body composition as contributors to skeletal health.

The 21st-century landscape of adult fractures: cohort study of a complete adult regional population

Recent reports on adult fracture epidemiology have focused mainly on the hip in the elderly, in whom increasing rates lately have changed to a decline. New reports of the preponderance of nonhip fractures in health expenditure call for a wider scope. We therefore examined current overall and site-specific fracture epidemiology in adults. We ascertained all fractures diagnosed in inpatient and outpatient care in all men and women aged 20 years or older in Skåne County, Sweden, from 1999 to 2010 (10 million person-years). For each fracture type, we estimated age-specific and sex-specific rates and evaluated potential time trends. We found 205,908 fractures yielding an overall fracture rate of 192 per 10,000 person-years. The age-standardized overall fracture rate increased by 1.2 per 10,000 and year (95% confidence interval, 0.8 to 1.5), but time trends were different for different fracture types, age strata, and for men and women. For example, in both women and men aged ≥50 years the rates of proximal humerus fracture increased (0.6 and 0.2 per 10,000 and year, respectively) while hip fracture rates declined (-1.0 and -0.3 per 10,000/year, respectively). Overall age-specific number of fractures increased with age in women but was stable in men. The increasing overall fracture rate is a major concern in the context of a growing and aging population. Effective and affordable preventive strategies and treatments should be an urgent priority to meet the challenges, especially in older women in whom most fractures occur. Comprehensive current detailed data, as provided in this study, may serve as reference for projections and for cost calculations of fracture care in other settings before results of similar examinations are available there.

Ten-year incident osteoporosis-related fractures in the population-based Canadian Multicentre Osteoporosis Study - comparing site and age-specific risks in women and men

BACKGROUND

Population-based incident fracture data aid fracture prevention and therapy decisions. Our purpose was to describe 10-year site-specific cumulative fracture incidence by sex, age at baseline, and degree of trauma with/without consideration of competing mortality in the Canadian Multicentre Osteoporosis Study adult cohort.

METHODS

Incident fractures and mortality were identified by annual postal questionnaires to the participant or proxy respondent. Date, site and circumstance of fracture were gathered from structured interviews and medical records. Fracture analyses were stratified by sex and age at baseline and used both Kaplan-Meier and competing mortality methods.

RESULTS

The baseline (1995-97) cohort included 6314 women and 2789 men (aged 25-84 years; mean±SD 62±12 and 59±14, respectively), with 4322 (68%) women and 1732 (62%) men followed to year-10. At least one incident fracture occurred for 930 women (14%) and 247 men (9%). Competing mortality exceeded fracture risk for men aged 65+years at baseline. Age was a strong predictor of incident fractures especially fragility fractures, with higher age gradients for women vs. men. Major osteoporotic fracture (MOF) (hip, clinical spine, forearm, humerus) accounted for 41-74% of fracture risk by sex/age strata; in women all MOF sites showed age-related increases but in men only hip was clearly age-related. The most common fractures were the forearm for women and the ribs for men. Hip fracture incidence was the highest for the 75-84 year baseline age-group with no significant difference between women 7.0% (95% CI 5.3, 8.9) and men 7.0% (95% CI 4.4, 10.3).

INTERPRETATION

There are sex differences in the predominant sites and age-gradients of fracture. In older men, competing mortality exceeds cumulative fracture risk.

Burden of illness for osteoporotic fractures compared with other serious diseases among postmenopausal women in the United States

OBJECTIVES

To provide a national estimate of the incidence of hospitalizations due to osteoporotic fractures (OFs) in women; compare this with the incidence of myocardial infarction (MI), stroke, and breast cancer; and assess temporal trends in the incidence and length of hospitalizations.

PATIENTS AND METHODS

The study included all women 55 years and older at the time of admission, admitted to a hospital participating in the US Nationwide Inpatient Sample for an outcome of interest. We performed a retrospective analysis of hospitalizations for OFs (hip, forearm, spine, pelvis, distal femur, wrist, and humerus), MI, stroke, or breast cancer, using the US Nationwide Inpatient Sample, 2000-2011.

RESULTS

From 2000 to 2011, there were 4.9 million hospitalizations for OF, 2.9 million for MI, 3.0 million for stroke, and 0.7 million for breast cancer. Osteoporotic fractures accounted for more than 40% of the hospitalizations in these 4 outcomes, with an age-adjusted rate of 1124 admissions per 100,000 person-years. In comparison, MI, stroke, and breast cancer had age-adjusted incidence rates of 668, 687, and 151 admissions per 100,000 person-years, respectively. The annual total population facility-related hospital cost was highest for hospitalizations due to OFs ($5.1 billion), followed by MI ($4.3 billion), stroke ($3.0 billion), and breast cancer ($0.5 billion).

CONCLUSION

These data provide evidence that in US women 55 years and older, the hospitalization burden of OFs and population facility-related hospital cost is greater than that of MI, stroke, or breast cancer. Prioritization of bone health and supporting programs such as fracture liaison services is needed to reduce this substantial burden.

Insights from the Global Longitudinal Study of Osteoporosis in Women (GLOW)

GLOW is an observational, longitudinal, practice-based cohort study of osteoporosis in 60,393 women aged ≥55 years in 10 countries on three continents. In this Review, we present insights from the first 3 years of the study. Despite cost analyses being frequently based on spine and hip fractures, we found that nonvertebral, nonhip fractures were around five times more common and doubled the use of health-care resources compared with hip and spine fractures combined. Fractures not at the four so-called major sites in FRAX(®) (upper arm, forearm, hip and clinical vertebral fractures) account for >40% of all fractures. The risk of fracture is increased by various comorbidities, such as Parkinson disease, multiple sclerosis and lung and heart disease. Obesity, although thought to be protective against all fractures, substantially increased the risk of fractures in the ankle or lower leg. Simple assessment by age plus fracture history has good predictive value for all fractures, but risk profiles differ for first and subsequent fractures. Fractures diminish quality of life as much or more than diabetes mellitus, arthritis and lung disease, yet women substantially underestimate their own fracture risk. Treatment rates in patients at high risk of fracture are below those recommended but might be too frequent in women at low risk. Comorbidities and the limits of current therapeutic regimens jeopardize the efficacy of drugs; new regimens should be explored for severe cases.

Obesity, health-care utilization, and health-related quality of life after fracture in postmenopausal women: Global Longitudinal Study of Osteoporosis in Women (GLOW)

Fractures may be associated with higher morbidity in obese postmenopausal women than in nonobese women. We compared health-care utilization, functional status, and health-related quality of life (HRQL) in obese, nonobese, and underweight women with fractures. Information from the GLOW study, started in 2006, was collected at baseline and at 1, 2, and 3 years. In this subanalysis, self-reported incident clinical fractures, health-care utilization, HRQL, and functional status were recorded and examined. Women in GLOW (n = 60,393) were aged ≥55 years, from 723 physician practices at 17 sites in 10 countries. Complete data for fracture and body mass index were available for 90 underweight, 3,270 nonobese, and 941 obese women with one or more incident clinical fractures during the 3-year follow-up. The median hospital length of stay, adjusted for age, comorbidities, and fracture type, was significantly greater in obese than nonobese women (6 vs. 5 days, p = 0.017). Physical function and vitality score were significantly worse in obese than in nonobese women, both before and after fracture; but changes after fracture were similar across groups. Use of antiosteoporosis medication was significantly lower in obese than in nonobese or underweight women. In conclusion, obese women with fracture undergo a longer period of hospitalization for treatment and have poorer functional status and HRQL than nonobese women. Whether these differences translate into higher economic costs and adverse effects on longer-term outcomes remains to be established.

Age-period-cohort effects in the incidence of hip fractures: political and economic events are coincident with changes in risk

An age-period cohort model was fitted to analyse time effects on hip fracture incidence rates by sex (Portugal, 2000-2008). Rates increased exponentially with age (age effect). Incidence rates decreased after 2004 for women and were random for men (period effect). New but comprehensive fluctuations in risk were coincident with major political/economic changes (cohort effect).

INTRODUCTION

Healthcare improvements have allowed prevention but have also increased life expectancy, resulting in more people being at risk. Our aim was to analyse the separate effects of age, period and cohort on incidence rates by sex in Portugal, 2000-2008.

METHODS

From the National Hospital Discharge Register, we selected admissions (aged ≥ 49 years) with hip fractures (ICD9-CM, codes 820.x) caused by low/moderate trauma (falls from standing height or less), readmissions and bone cancer cases. We calculated person-years at risk using population data from Statistics Portugal. To identify period and cohort effects for all ages, we used an age-period-cohort model (1-year intervals) followed by generalised additive models with a negative binomial distribution of the observed incidence rates of hip fractures.

RESULTS

There were 77,083 hospital admissions (77.4 % women). Incidence rates increased exponentially with age for both sexes (age effect). Incidence rates fell after 2004 for women and were random for men (period effect). There was a general cohort effect similar in both sexes; risk of hip fracture altered from an increasing trend for those born before 1930 to a decreasing trend following that year. Risk alterations (not statistically significant) coincident with major political and economic change in the history of Portugal were observed around birth cohorts 1920 (stable-increasing), 1940 (decreasing-increasing) and 1950 (increasing-decreasing only among women).

CONCLUSIONS

Hip fracture risk was higher for those born during major economically/politically unstable periods. Although bone quality reflects lifetime exposure, conditions at birth may determine future risk for hip fractures.

Substantial under-treatment among women diagnosed with osteoporosis in a US managed-care population: a retrospective analysis

BACKGROUND

Multiple therapies are approved for the treatment of osteoporosis (OP), but many patients with osteoporosis may not initiate treatment upon osteoporosis diagnosis.

OBJECTIVE

To characterize initiation of pharmacologic OP treatment among women within 1 year of OP diagnosis in a US managed care population.

RESEARCH DESIGN AND METHODS

The retrospective cohort study included women aged ≥55 years with a claims-documented diagnosis of OP who were naïve to OP medications prior to OP diagnosis (index date) during 2001-2010. Continuous enrollment for 12 months before (baseline) and after (follow-up) the index date was required. Patients who received OP medications but did not have an OP diagnosis were excluded. Differences in baseline characteristics between the treated and untreated cohorts were compared using Wilcoxon rank-sum (continuous variables) and chi-square tests (categorical variables).

MAIN OUTCOMES MEASURES

During the follow-up period, the percentages of patients treated with bisphosphonates (alendronate, ibandronate, risedronate, zoledronic acid) and non-bisphosphonates (calcitonin, raloxifene, teriparatide) were determined.

RESULTS

A total of 65,344 patients, mean age 65.7 years, met study inclusion exclusion criteria. During the follow-up period, 42,033 patients (64.3%) received no OP medication and 23,311 patients (35.7%) received OP treatment. A total of 20,200 patients (30.9% of total study population) received bisphosphonates and 3111 (4.8% of total) patients received non-bisphosphonates as their index medication. At baseline, untreated patients were slightly older and had higher rates of hypertension, chronic inflammatory joint disease, diabetes mellitus, and gastrointestinal events (p ≤ 0.01) compared with treated patients.

CONCLUSIONS

Among women aged ≥55 years in a US managed-care population, 64.3% received no pharmacologic treatment within 1 year after being diagnosed with OP. The authors were not able to determine if untreated patients did not receive or did not fill a prescription. Further research is needed to understand the barriers to OP treatment and reasons for non-treatment.

Comprehensive classification of fragility fractures of the pelvic ring: Recommendations for surgical treatment

Due to the increasing life expectancy, orthopaedic surgeons are more and more often confronted with fragility fractures of the pelvis (FFPs). These kinds of fractures are the result of a low-energy impact or they may even occur spontaneously in patients with severe osteoporosis. Due to some distinct differences, the established classifications for pelvic ring lesions in younger adults do not fully reflect the clinical and morphological criteria of FFPs. Most FFPs are minimally displaced and do not require surgical therapy. However, in some patients, an insidious progress of bone damage leads to increasing displacement, nonunion and persisting instability. Therefore, new concepts for surgical treatment have to be developed to address the functional needs of the elderly patients. Based on an analysis of 245 consecutive patients with FFPs, we propose a novel classification system for this condition. This classification is based on morphological criteria and it corresponds with the degree of instability. Also in the elderly, these criteria are the most important for the decision on the type of treatment as well as type and extent of surgery. The estimation of the degree of instability is based on radiological and clinical findings. The classification gives also hints for treatment strategies, which may vary between minimally invasive techniques and complex surgical reconstructions.

Public health impact of osteoporosis

OBJECTIVE

To describe the public health impact of osteoporosis including the magnitude of the problem and important consequences of osteoporotic fractures.

METHODS

Literature review of key references selected by author.

RESULTS

Current demographic trends leading to an increased number of individuals surviving past age 65 will result in an increased number of osteoporotic fractures. Important consequences of osteoporotic fractures include an increased mortality that for hip fractures extends to 10 years after the fracture. Increased mortality risk also extends to major and minor fractures, especially, in those over 75 years. Hip and vertebral fractures have important functional consequences and reductions in quality of life. The economic impact of osteoporotic fractures is large and growing. Significant health care resources are required for all fractures.

CONCLUSIONS

To alleviate the public and private burden of osteoporosis related fractures, assessment of risk and reduction of individual risk is critical.

Osteoporotic hip fractures: bisphosphonates sales and observed turning point in trend. A population-based retrospective study

The aim is to examine the temporal trends of hip fracture incidence in Portugal by sex and age groups, and explore the relation with anti-osteoporotic medication. From the National Hospital Discharge Database, we selected from 1st January 2000 to 31st December 2008, 77,083 hospital admissions (77.4% women) caused by osteoporotic hip fractures (low energy, patients over 49years-age), with diagnosis codes 820.x of ICD 9-CM. The 2001 Portuguese population was used as standard to calculate direct age-standardized incidence rates (ASIR) (100,000 inhabitants). Generalized additive and linear models were used to evaluate and quantify temporal trends of age specific rates (AR), by sex. We identified 2003 as a turning point in the trend of ASIR of hip fractures in women. After 2003, the ASIR in women decreased on average by 10.3 cases/100,000 inhabitants, 95% CI (-15.7 to -4.8), per 100,000 anti-osteoporotic medication packages sold. For women aged 65-69 and 75-79 we identified the same turning point. However, for women aged over 80, the year 2004 marked a change in the trend, from an increase to a decrease. Among the population aged 70-74 a linear decrease of incidence rate (95% CI) was observed in both sexes, higher for women: -28.0% (-36.2 to -19.5) change vs -18.8%, (-32.6 to -2.3). The abrupt turning point in the trend of ASIR of hip fractures in women is compatible with an intervention, such as a medication. The trends were different according to gender and age group, but compatible with the pattern of bisphosphonates sales.