Outcomes post fragility fracture among members of an integrated healthcare organization

Prediction models incorporating second metacarpal cortical index for osteoporosis in rheumatoid arthritis: Externally validated machine learning models developed using data from the KURAMA cohort

OBJECTIVE

Osteoporosis and osteopenia are significant concerns in rheumatoid arthritis (RA), predisposing patients to fragility fractures. While dual-energy X-ray absorptiometry (DXA) is the gold standard for bone mineral density (BMD) assessment, simpler screening tools are needed. This study aims to assess the correlation between the second metacarpal cortical index (2MCI) and BMD in RA patients, and to evaluate machine learning (ML) models utilizing 2MCI and clinical parameters for predicting osteoporosis/osteopenia presence and BMD.

METHODS

Data from the KURAMA cohort (n = 302) and an external validation cohort (n = 32) were analyzed. BMD in the hip and forearm was obtained using DXA and 2MCI was calculated from plain hand X-ray. ML models were trained to predict osteoporosis/osteopenia presence and BMD using 2MCI and clinical variables and validated using external cohort.

RESULTS

2MCI correlated significantly with hip and forearm BMD. ML models incorporating 2MCI and other clinical parameters showed good performance in predicting osteoporosis/osteopenia presence and BMD. External validation demonstrated the generalizability of the models.

CONCLUSION

ML models utilizing 2MCI and clinical parameters show promise for osteoporosis screening in RA patients.

Refracture and mortality risk in the elderly with osteoporotic fractures: the AGES-Reykjavik study

There is imminent refracture risk in elderly individuals for up to six years, with a decline thereafter except in women below 75 who face a constant elevated risk. Elderly men with fractures face the highest mortality risk, particularly those with hip and vertebral fractures. Targeted monitoring and treatment strategies are recommended.

PURPOSE

Current management and interventions for osteoporotic fractures typically focus on bone mineral density loss, resulting in suboptimal evaluation of fracture risk. The aim of the study is to understand the progression of fractures to refractures and mortality in the elderly using multi-state models to better target those at risk.

METHODS

This prospective, observational study analysed data from the AGES-Reykjavik cohort of Icelandic elderly, using multi-state models to analyse the evolution of fractures into refractures and mortality, and to estimate the probability of future events in subjects based on prognostic factors.

RESULTS

At baseline, 4778 older individuals aged 65 years and older were included. Elderly men, and elderly women above 80 years of age, had a distinct imminent refracture risk that lasted between 2-6 years, followed by a sharp decline. However, elderly women below 75 continued to maintain a nearly constant refracture risk profile for ten years. Hip (30-63%) and vertebral (24-55%) fractures carried the highest 5-year mortality burden for elderly men and women, regardless of age, and for elderly men over 80, lower leg fractures also posed a significant mortality risk.

CONCLUSION

The risk of refracture significantly increases in the first six years following the initial fracture. Elderly women, who experience fractures at a younger age, should be closely monitored to address their long-term elevated refracture risk. Elderly men, especially those with hip and vertebral fractures, face substantial mortality risk and require prioritized monitoring and treatment.

Association between a history of major osteoporotic fractures and subsequent hip fracture: a systematic review and meta-analysis

PURPOSE

A history of fractures involving the distal radius, proximal humerus, spine, and hip may be associated with the incidence of subsequent hip fractures in older people. However, a comprehensive summary of this association using a rigorous methodology is lacking. Our objective was to systematically review the literature and examine the association between four major osteoporotic fractures and subsequent hip fractures in individuals aged ≥ 50 years.

METHODS

We searched MEDLINE, Embase, CENTRAL, ICTRP, and ClinicalTrials.gov on February 15, 2023. The search included cohort or case-control studies investigating the association between these four types of osteoporotic fractures and subsequent hip fractures. We pooled the hazard ratios (HRs) with 95% confidence intervals (CI) using the random-effects model. We used the Quality In Prognosis Studies tool to assess the risk of bias in the included studies, and the grading of recommendations assessment, development, and evaluation approach to determine the certainty of evidence.

RESULTS

The selection process identified 48 studies for qualitative synthesis and 23 studies (2,239,217 participants) for meta-analysis. The overall methodological quality had a low risk of bias in 65% of the included studies. The association between a history of major osteoporotic fractures and subsequent hip fracture varied, with a high certainty of evidence for a history of proximal humerus and hip fractures (HR 2.02, 95% CI 1.75-2.33 and 2.86, 95% CI 1.92-4.25, respectively), moderate certainty for distal radius fractures (HR 1.66, 95% CI 1.53-1.81), and low certainty for spine fractures (HR 1.53, 95% CI 1.38-1.69).

CONCLUSIONS

In conclusion, a history of major osteoporotic fractures, particularly distal radius, proximal humerus, and hip fractures, is associated with subsequent hip fractures in older adults. Further research is needed to verify the association between a history of spine fracture and subsequent hip fractures.

PROTOCOL REGISTRATION

Open Science Framework ( https://osf.io/7fjuc ).

Global, regional, national trends of femur fracture and machine learning prediction: Comprehensive findings and questions from global burden of disease 1990-2019

Background

Femur fracture is a type of fracture with high disability and mortality. There is no comprehensive analysis and prediction of the global distribution of femur fractures, so we conducted this study.

Methods

Age-standardized incidence rate (ASIR), age-standardized prevalence rate (ASPR), and years living with disability (YLDs) of femur fractures (excluding femoral neck) were downloaded from the Global burden of disease database. Trend analysis was performed, and 6 time-series machine learning algorithms were applied to predict the global ASIR, ASPR, and YLDs.

Results

ASPR for femur fracture had been increasing in most countries worldwide from 1990 to 2019, with the highest in East Asia (AAPC = 1.25 95%Confidence Interval (1.2, 1.3)) and lowest in Central Latin America (AAPC = -0.74 95%CI (-0.81, -0.67)). However, ASIR showed a significant downward trend worldwide, with East Saharan Africa decreasing the most (AAPC = -4.04 95%CI (-5.56, -2.47)), and East Asia elevating the most (AAPC = 1.11 95%CI (0.87, 1.42)). YLDs were increasing over the world, with East Asia still elevating the most AAPC= (3.9 95%CI (3.85, 3.95)), with the only region of decrease being Eastern Europe (AAPC = -0.28 95%CI (-0.3, -0.26)). Both ASPR and ASIR were higher in women than in men in the >75 year group, whereas YLDs was lower in women than in men in the >60 year group. Globally, the ARIMA model was optimal in the prediction of ASPR, the PROPHET model effected in the prediction of ASIR, and the PROPHET WITH XGBOOST model was the best in the prediction of YLDs. The projections showed increase in both ASPR and YLDs, except for ASIR decreasing by 2030.

Conclusions

Our study found a rise in femur fracture ASPR and ASIR from 1990 to 2019 in war conflict areas and East Asia, meanwhile, the YLDs of femur fracture increased in populous countries. In both 1990 and 2019, both ASPR and ASIR were higher in women over 75 years than that in men, but YLDs was higher in men over 60 years than that in women. In 2020-2030, while global femur fracture ASIR might decline, both ASPR and YLDs might rise.

The Translational Potential of this article

Femur fracture is a high-energy injury due to direct violence, and in war, conflicting and underdeveloped regions such as East Asia. Accidental injuries may occur due to the rapid development of industry and the frequent traffic accidents. This study suggests that we should focus on elderly women (≥75 years) in the above regions in the future. For older men (>60 years old), more attention should be paid to post-fracture functional rehabilitation and early reintegration into society to reduce the disability rate and lower the socio-economic burden.

Achieving osteoporosis treat-to-target goals with teriparatide or alendronate: sub-analysis of Japanese Osteoporosis Intervention Trial-05 (JOINT-05)

INTRODUCTION

The purpose of this study was to evaluate whether bone mineral density (BMD) ≥ -2.5 SD could be used as the treat-to-target (T2T) goal when treating osteoporosis with teriparatide (TPTD) and alendronate (ALN), and to investigate the relationship with incident vertebral fracture by re-analyzing data from a randomized, controlled trial (JOINT-05) involving postmenopausal Japanese women at high fracture risk.

MATERIALS AND METHODS

Participants received sequential therapy with once-weekly TPTD for 72 weeks, followed by ALN for 48 weeks (TPTD-ALN group) or ALN monotherapy for 120 weeks (ALN group). BMDs were measured at the lumbar spine (L2-4), total hip, and femoral neck at 0, 24, 48, 72, and 120 weeks by dual-energy X-ray absorptiometry. The T2T goal was BMD ≥ -2.5 SD, and the endpoint was the proportion of participants with baseline BMD < -2.5 SD in three measurement sites achieving BMD ≥ -2.5 SD.

RESULTS

A total of 559 participants were selected. BMD ≥ -2.5 SD at 120 weeks in the L2-4, total hip, and femoral neck sites was achieved in 20.5%, 23.1%, and 5.9%, respectively, in the TPTD-ALN group and 22.2%, 11.7%, and 7.3%, respectively, in the ALN group. Incident vertebral fractures occurred in areas of both lower and high BMD.

CONCLUSION

During the 1.5-year treatment period, more than 20% of participants achieved BMD ≥ -2.5 SD as a T2T goal at L2-4. Since the achievement level differed depending on the BMD measurement site, the appropriate site should be selected according to the baseline BMD level.

Hidden blood loss and its risk factors in percutaneous vertebroplasty surgery for osteoporotic vertebral compression fractures

OBJECTIVES

Percutaneous vertebroplasty (PVP) is a percutaneous interventional procedure for osteoporotic vertebral compression fractures (OVCFs). However, hidden blood loss (HBL) during the surgery is easily disregarded. This study aimed to evaluate HBL and its possible risk factors in the patients following PVP for OVCFs.

METHODS

Patients with OVCFs who underwent PVP surgery between January 2019 and November 2022 at our hospital were retrospectively analyzed. Patients' demographics, laboratory data, and imaging and clinical date were also collected. Preoperative and postoperative hematocrit were recorded, the hidden blood loss was calculated according to Sehat formula, and the risk factors were analyzed by multivariate linear regression analysis.

RESULTS

One hundred and fifty-five patients (26 males and 129 females) were retrospectively enrolled in this study. 85.2% of patients had one segment vertebral fracture and the mean surgical time was 30.5 ± 11.0 min. No intraspinal cement leakage occurred. The mean HBL was 204.0 ± 89.6 ml. Multivariate linear regression analysis revealed that HBL was positively associated with number of fracture segments (P = 0.001), degree of vertebral height restoration (P = 0.001), surgical time (P = 0.000), number of puncture (P = 0.002), and cement leakage (P = 0.038).

CONCLUSIONS

Multiple vertebral fractures, higher degree of vertebral height restoration, longer surgical time, more number of puncture, and cement leakage are independent risk factors for HBL. Therefore, HBL should not be neglected in the patients with OVCFs undergoing PVP surgery, especially in those with poor preoperative physical condition and presence of anemia.

Evaluation of post-acute care and one-year outcomes among Medicare beneficiaries with hip fractures: a retrospective cohort study

BACKGROUND

Post-acute care (PAC) services after hospitalization for hip fracture are typically provided in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), or at home via home health care (HHC). Little is known about the clinical course following PAC for hip fracture. We examined the nationwide burden of adverse outcomes by PAC setting in the year following discharge from PAC for hip fracture.

METHODS

This retrospective cohort included Medicare Fee-for-Service beneficiaries > 65 years who received PAC services in U.S. SNFs, IRFs, or HHC following hip fracture hospitalization between 2012 and 2018. Individuals who had a fall-related injury (FRI) during PAC or received PAC services in multiple settings were excluded. Primary outcomes included FRIs, all-cause hospital readmissions, and death in the year following discharge from PAC. Cumulative incidences and incidence rates for adverse outcomes were reported by PAC setting. Exploratory analyses examined risk ratios and hazard ratios between settings before and after inverse-probability-of-treatment-weighting, which accounted for 43 covariates.

RESULTS

Among 624,631 participants (SNF, 67.78%; IRF, 16.08%; HHC, 16.15%), the mean (standard deviation) age was 82.70 (8.26) years, 74.96% were female, and 91.30% were non-Hispanic White. Crude incidence rates (95%CLs) per 1000 person-years were highest among individuals receiving SNF care for FRIs (SNF, 123 [121, 123]; IRF, 105 [102, 107]; HHC, 89 [87, 91]), hospital readmission (SNF, 623 [619, 626]; IRF, 538 [532, 544]; HHC, 418 [414, 423]), and death (SNF, 167 [165, 169]; IRF, 47 [46, 49]; HHC, 55 [53, 56]). Overall, rates of adverse outcomes generally remained higher among SNF care recipients after covariate adjustment. However, inferences about the group with greater adverse outcomes differed for FRIs and hospital readmissions based on risk ratio or hazard ratio estimates.

CONCLUSIONS

In this retrospective cohort study of individuals hospitalized for hip fracture, rates of adverse outcomes in the year following PAC were common, especially among SNF care recipients. Understanding risks and rates of adverse events can inform future efforts to improve outcomes for older adults receiving PAC for hip fracture. Future work should consider calculating risk and rate measures to assess the influence of differential time under observation across PAC groups.

The impact of prior fragility fractures on long-term periprosthetic fracture risk following total knee arthroplasty

The study found that patients undergoing total knee arthroplasty with prior fragility fracture had increased risk of subsequent fragility fracture and periprosthetic fracture within 8 years postoperatively when compared to those without a prior history. However, these patients were not at increased risk for all-cause revision within this period.

PURPOSE

The aim of this study was to characterize the association of prior FFs on long-term risk of secondary fragility fracture (FF), periprosthetic fracture (PPF), and revision TKA.

METHODS

Patients at least 50 years of age who underwent elective TKA were identified in the PearlDiver Database. Patients were stratified based on whether they sustained a FF within 3 years prior to TKA (7410 patients) or not (712,954 patients). Demographics and comorbidities were collected. Kaplan Meier analysis was used to observe the cumulative incidence of all-cause revision, PPF, and secondary FF within 8 years of TKA. Cox Proportional hazard ratio analysis was used to statistically compare the risk.

RESULTS

In total, 1.0% of patients had a FF within three years of TKA. Of these patients, only 22.6% and 10.9% had a coded diagnosis of osteoporosis and osteopenia, respectively, at time of TKA. The 8-year cumulative incidence of secondary FF and periprosthetic fracture was significantly higher in those with a prior FF (27.5% secondary FF and 1.9% PPF) when compared to those without (9.1% secondary FF and 0.7% PPF). After adjusting for covariates, patients with a recent FF had significantly higher risks of secondary FF (HR 2.73; p < 0.001) and periprosthetic fracture (HR 1.86; p < 0.001) than those without a recent FF.

CONCLUSIONS

Recent FF before TKA is associated with increased risk for additional FF and PPF within 8 years following TKA. Surgeons should ensure appropriate management of fragility fracture is undertaken prior to TKA to minimize fracture risk, and if not, be vigilant to identify patients with prior FF or other bone health risk factors who may have undocumented osteoporosis.

Osteoporosis management and secondary fragility fracture rates in patients with multiple sclerosis: a matched cohort study

This study highlights the persistent osteoporosis treatment gap following fragility fractures. Patients with multiple sclerosis sustained more primary hip fractures than controls and exhibited significantly higher rates of falls within three years post-fracture. However, multiple sclerosis (MS) patients were significantly more likely to be diagnosed with osteoporosis and treated with medications.

INTRODUCTION

The purpose of this study was to compare rates of osteoporosis management, falls, and secondary fractures following primary fragility fractures among patients with MS versus matched controls.

MATERIALS AND METHODS

A retrospective matched cohort study was conducted using the PearlDiver database. Patients aged ≥ 50 years with primary fragility fractures were identified (n = 120,368). Within this population, patients with MS were matched 1:10 with controls across age, sex, and US region. Rates of osteoporosis diagnoses and pharmacologic treatment, low-energy falls, and secondary fragility fractures were compared at three years post-fracture via logistic regression.

RESULTS

A total of 1,232 patients with MS (mean age, 65.7 years) with primary fragility fractures were matched with 12,320 controls (mean age, 65.8 years). Primary hip fractures were significantly more common in the MS cohort (47.4% vs. 34.2%, p < 0.001). After the initial fracture, patients with MS were significantly more likely to receive a formal osteoporosis diagnosis (12.9% vs. 9.7%; OR 1.35; 95% CI, 1.13-1.61) and osteoporosis pharmacotherapy (14.4% vs. 11.9%; OR 1.24; 95% CI, 1.04-1.46). The MS cohort also exhibited significantly higher rates of falls (27.8% vs 22.7%; OR 1.15; 95% CI, 1.01-1.32). Rates of secondary fractures were comparable (6.3% vs. 5.0%; OR 1.10; 95% CI, 0.85-1.40).

CONCLUSION

Primary hip fragility fractures were significantly more common in patients with MS compared to matched controls. Following an initial fracture, patients with MS exhibited a significantly higher rate of falls but were more likely to be diagnosed with osteoporosis and treated with medications.