The burden of osteoporosis in Turkey: a scorecard and economic model

Conversion arthroplasty after failed extracapsular hip fracture fixation is associated with high complication rates

Background/Aim: There is no standard treatment of choice that addresses all extracapsular fractures, which account for approximately half of the elderly hip fractures. Arthroplasty is mostly favored secondary to unsuccessful fixation or unstable primary fractures. However, conversion arthroplasty complication rates are high in the literature. This study compares arthroplasty performed after unsuccessful fixation and primary arthroplasty for unstable extracapsular hip fractures. Methods: In this retrospective study, we compared the first-year results of the groups that underwent conversion arthroplasty (cHA) and the primary arthroplasties (pHA) for extracapsular hip fractures. In the cHA group, patients were indicated for operation if there was a failure of fixation after extracapsular hip fractures (n=44). In the pHA group, patients were for unstable extracapsular hip fractures (n=44). In the cHA group, failure of fixation causes were cut-out of lag screws (54.5%), cut-through of lag screws (9.1%), non-union of fractures (27.3%), and osteonecrosis of femoral heads (9.1%). While total hip replacement was applied to all patients in the cHA group, total hip replacement was applied to ten patients in the pHA group and hemiarthroplasty to 34 patients. In comparing groups, duration of operation, amount of bleeding, intraoperative complications, post-operative complications, mobilization capacities, functional status, and mortality rates were used. Results: There were 44 patients in both groups. The surgical time (134.3 [34.5)] vs. 66 [16], [P<0.001]), the amount of bleeding (1000 ml [400] vs. 300ml [200], [P<0.001]), the need for red blood cell transfusion in the operations (80% vs. 32%, [P<0.001]), and the frequency of intraoperative femur fracture (30% vs. 0%, [P<0.001]) were larger or longer in the cHA group compared to pHA group (P<0.001). While 14 complications requiring surgical intervention were observed in 12 of 44 patients in the CHA group in the post-operative 1st year, four complications were observed in four of 44 patients in the pHA group. There was no difference in mortality rates (3 vs. 3, [P =1]), mobilization capacities (5.9 [2.1] vs. 5.7 [2.0], [P=0.597]), and functional status (12.5 [3.3] vs. 13.0 [2.7], [P=0.434]) between the groups. Conclusion: Arthroplasty performed as conversion surgery after unsuccessful fixation has a higher risk of intraoperative and post-operative complications than primary arthroplasty performed after extracapsular hip fractures. We believe the cases prone to implant failure, non-union, or restricted mobilization because of the patient and fracture-type reasons should be treated with primary arthroplasty.

The complex impedance phase angle of dominant arm: a useful parameter in bone mineral density (BMD) assessment of group 1 post-menopausal women

For widespread osteoporosis (OP) screening, portable and cost-effective screening devices are needed. With 45 menopaused women, when body mass index was below 30 kg.m^- 2, the phase angle (PhA) of complex bioimpedance at 5 kHz, measured from the dominant arm, was correlated with dual-energy X-ray absorptiometry (DEXA) measured central bone mineral densities (BMD), for total hip r = 0.493 and for total lumbar r = 0.411, P< 0.05, and the strength of correlation decreased with increasing measurement frequencies. ANOVA tests showed that, below 15 kHz, PhA was a descriptive marker for bone mineral deficiency. By correlating to hip and lumbar bone mineral densities simultaneously, the dominant arm segment PhA was superior to the characteristic frequency f_c of the body impedance spectroscopy (BIS) and the PhA of whole-body impedance measurements, of the earlier research works. Due to its medium correlation strength with central BMDs, a PhA measuring device could be considered as a complementary tool to the gold standard (DEXA), for OP screening of group 1 post-menopausal women only. For group 2, with 44 subjects with body mass indices over 30 kg.m^- 2, i.e., obese population, the PhA was not correlated with BMD and was no longer a descriptive marker for reduced BMD.

The economic burden of osteoporosis in Iran in 2020

Osteoporosis, the most common metabolic bone disease, leads to increased susceptibility to fractures. In 2020, about 150,000 osteoporotic fractures occurred in Iran. Osteoporosis and related fractures cost the community US$ 393 million. Introduction The present study aimed at estimating the economic burden of osteoporosis in Iran in 2020.

METHODS

We estimated the annual economic burden of osteoporosis in the above 50 years old population using a prevalence-based approach and from a societal perspective. The incidence of osteoporosis and related fractures were estimated based on meta-analysis reports in Iran and international comparisons. The direct medical and non-medical costs as well as the monetary value of quality-adjusted life-years (QALYs) lost because of fractures were estimated. Cost data were extracted from patient records, medical services prices, and previous literature.

RESULTS

A total of 154,530 osteoporotic fractures were estimated in Iran in 2020. The shares of the hip, vertebral, forearm, and other fractures were 14%, 15%, 17%, and 54%, respectively. There were also 3554 deaths from osteoporotic fractures. The economic burden of osteoporosis in Iran was estimated at US$ 393.24 million (US$ 2165 million purchasing power parity 2020). Direct medical and non-medical cost (47.44%), QALY loss (29.65%), and long-term care for prior hip fracture costs (9.4%) were the main component of the economic burden of osteoporosis.

CONCLUSION

The economic burdens of osteoporosis are significant in Iran. Interventions to prevent osteoporosis and especially associated fractures, such as screening and prophylaxis, can reduce the cost of the disease and improve patients' quality of life. Further studies are needed to identify cost-effective and feasible interventions in Iran.

Changes in dual energy X-ray absorptiometry parameters in postmenopausal women with osteoporosis who received at least 12 months of denosumab treatment

Background/Aim: Denosumab is a human monoclonal antibody that binds to the receptor-activated nuclear factor kappa beta ligand (RANKL). Densosumab leads to a reduction in bone resorption by inhibiting RANKL and has been approved for treating postmenopausal osteoporosis (OP). The present study investigated real life data by evaluating the demographic data of postmenopausal patients with OP who received denosumab treatment and the changes in dual energy x-ray absorptiometry (DEXA) parameters before and after denosumab treatment. Methods: This retrospective cohort study included 49 postmenopausal female patients followed in our OP outpatient clinic who were treated with 60 mg subcutaneous denosumab every six months for at least 12 months. The study retrospectively analyzed and recorded patient age, body mass index, age of menopause, fracture history, antiresorptive and/or anabolic drug treatment history, and pre- and post-denosumab T-scores in addition to L1–4, femoral neck, and total hip bone mineral densities (BMDs) on DEXA scans. The changes that occurred before and after the treatment in addition to those that occurred after the treatment based on whether previous anabolic or antiresorptive agents had been used were statistically compared. Results: The L1–4 and total hip T-scores and L1–4 and total hip BMD values measured prior to denosumab treatment showed a statistically significant increase after denosumab treatment (P < 0.001, P = 0.002, P = 0.028, and P = 0.002, respectively). No statistically significant changes in the femoral neck T-score and BMD after denosumab treatment compared to that before denosumab use (P = 0.056 and P = 0.138, respectively) were found. Furthermore, no statistically significant difference between the pre- and post-denosumab DEXA parameters in the patients who used antiresorptive agents and those who did not (P > 0.05) was found. Additionally, pre- and post-denosumab parameters were not statistically significantly different between those who received and did not receive anabolic therapy before denosumab (P > 0.05). Conclusion: Denosumab treatment for postmenopausal OP leads to a significant increase in lumbar and total hip T-scores and BMDs.

The current situation in the approach to osteoporosis in older adults in Turkey: areas in need of improvement with a model for other populations

PURPOSE

The total number of older adults in Turkey is striking, amounting to around 8 million, and this translates into considerably higher numbers of cases of osteoporosis (OP) and fractures in older adults. In this article, we outlined the current situation of OP in older adults in Turkey and investigated the differences between Turkey and a representative developed European country (Belgium), in terms of the screening, diagnosis, and treatment of OP. Our intention in this regard was to identify areas in need of improvement and subsequently to make a clear call for action to address these issues.

METHODS

Herein, considering the steps related to the OP approach, we made a complete review of the studies conducted in Turkey and compared with the literature recommendations.

RESULTS

There is a need for a national osteoporotic fracture registry; measures should be taken to improve the screening and treatment of OP in older males, such as educational activities; technicians involved in dual-energy X-ray absorptiometry (DXA) scanning should undergo routine periodic training; all DXA centers should identify center-specific least significant change values; all older adults should be considered for routine lateral dorsolumbar X-ray imaging for the screening of vertebral fractures while ordering DXA scans; the inclusion of vertebral fracture assessment (VFA) software in DXA assessments should be considered; screening using a fracture risk assessment tool (FRAX) algorithm that is specific to Turkey should be integrated; the fortification of foods with vitamin D is required; the high fracture risk by country-specific FRAX algorithm and the presence of falls/high fall risk should be integrated in reimbursement terms; and finally, more "fracture liaison services" should be established.

CONCLUSION

We suggest that the practical consideration of our suggestions will provide considerable support to the efforts for combating with the adverse consequences of OP in society. This approach can be subsequently modeled for other populations to improve the management of OP globally.